Provider Guide to FreedomBlue
Table of Contents
In this manual
/ This manual contains information on the topics listed below:Topic / See Page
FreedomBlue: A Medicare Advantage PPO from Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania / 3
The Rights of FreedomBlue Members / 6
The Responsibilities of FreedomBlue Members / 8
Characteristics of PPO Programs / 9
Medical Management Requirements: Authorization of Inpatient Admissions / 10
Medical Management Requirements: Transfers / 12
Medical Management Requirements: No Authorization Required for Emergency Services / 13
Medical Management Requirements: Outpatient Services / 14
Medical Management Requirements: Outpatient Therapies / 15
Medical Management Requirements for Medical Services: Mechanics of the Authorization Process / 17
Medical Management Requirements: Outpatient Mental Health and Substance Abuse Treatment Services / 18
Authorization, Benefits and Reimbursement / 19
Facility Denials / 20
Requesting a Retrospective Review / 21
Processes Specific to Medicare Advantage Members: Pre-Service Denials / 22
Processes Specific to Medicare Advantage Members: Notice of Discharge and Medicare Appeal Rights (NODMAR) for Hospitals / 23
Processes Specific to Medicare Advantage Members: Notice of Medicare Non-Coverage (Skilled Nursing Facility) / 25
Processes Specific to Medicare Advantage Members: Notice of Medicare Non-Coverage (Home Health Agency) / 29
Facility Appeal Process: FreedomBlue / 33
Submitting a Standard Appeal of an Initial Adverse Medical Necessity Decision: Concurrent Denial / 34
Submitting a Standard Appeal of an Initial Adverse Medical Necessity Decision: Retrospective Denial / 35
Facility Filing an Appeal on Behalf of a FreedomBlue Member / 36
Continued on next page
Table of Contents, Continued
Topic / See Page
Appealing a Pre-Service or Concurrent Denial on Behalf of a FreedomBlue Member / 38
Appealing a Post-Service Denial on Behalf of a FreedomBlue Member / 40
Important Telephone Numbers / 41
FreedomBlue: A Medicare Advantage PPO Product from Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania
FreedomBlue: A Medicare Advantage PPO from Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania
/ FreedomBlue is a Medicare Advantage Preferred Provider Organization (PPO) product from Highmark Blue Shield in association with Blue Cross of Northeastern Pennsylvania. It offers Medicare-eligible individuals the convenience of a PPO arrangement, through which covered health care services are reimbursed at the highest level when members receive these services from network providers. Most services performed by non-network providers are also covered, with a higher level of member cost-sharing.FreedomBlue is administered by Highmark Blue Shield in association with Blue Cross of Northeastern Pennsylvania, in accordance with regulations of the Centers for Medicare and Medicaid Services (CMS).
“Medicare Advantage” programs
/ In an effort to make broader and more cost-effective coverage options available to people eligible for Medicare, the Health Care Financing Administration (HCFA, now known as the Centers for Medicare and Medicaid Services) created “Medicare Part C.”This term includes a wide variety of delivery models – including Preferred Provider Organizations -- which serve as replacements for Original Medicare. All of these models are funded through a combination of payments from the Medicare program and the member’s premium.
Such plans were originally known as “Medicare+Choice” plans but now are called “Medicare Advantage” programs.
Medicare participation
/ To be included in a Medicare Advantage provider network, a provider must participate in the Medicare program itself.At least the benefits provided under Original Medicare
/ At a minimum, Medicare Advantage programs such as FreedomBlue are required to provide coverage for the services covered by Original Medicare. They may also provide additional services and benefits.FreedomBlue offers its members additional benefits and services beyond those covered by the Medicare program. These include preventive services, routine dental and vision care and prescription drugs (including a Medicare-approved prescription drug discount card).
FreedomBlue: A Medicare Advantage PPO Product from Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania Blue Cross of Northeastern Pennsylavania, Continued
Latitude in delivering covered benefits
/ Please note that while Medicare Advantage plans are required to provide at least the same benefits offered to members with Original Medicare coverage, they have latitude in the way those covered benefits are applied. Medicare Advantage plans can, for example, apply medical management requirements and define the network within which services can be rendered.Medical policy
/ To the extent that it is available, Medicare Advantage medical policy applies to all services provided to members with coverage under FreedomBlue. If no Medicare Advantage medical policy exists on a particular topic, Highmark Blue Shield medical policy applies.Like Highmark Blue Shield’s own medical policy information, Medicare Advantage Medical Policy is available via the Blue Cross of Northeastern Pennsylvania-hosted NaviNet portal or Secure Access or the Highmark Blue Shield-hosted Navinet System.
Support services
/ FreedomBlue Members also have access to support services such as the following:· SilverSneakers® Fitness Program membership to encourage health and well-being through exercise
· Computer-delivered lifestyle improvement programs on topics such as weight management, nutrition, smoking cessation and stress management
· Dr. Dean Ornish Program for Reversing Heart Disease, available to all medically qualified members
· Highmark Osteoporosis Prevention and Education (HOPE), for members diagnosed with or at risk for developing osteoporosis
· Blues On CallSM Health Information and Decision Support Line, a toll-free service which supports members’ relationship with their physicians by providing information to support well-informed questions and decision-making
Continued on next page
FreedomBlue: A Medicare Advantage PPO Product from Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania Blue Cross of Northeastern Pennsylvania, Continued
CMS regulation
/ Because Medicare Advantage programs are funded partly by the Medicare Program itself, it also regulates many administrative aspects of the program, including processes intended to safeguard members’ rights.For more information about these processes, please see pages 6 and 7.
The Rights of FreedomBlue Members
Members’ rights
/ FreedomBlue members have the right to…1. Be assured that they will not be discriminated against in the delivery of health care services consistent with the benefits of their plan, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment.
2. Receive considerate and courteous care, with respect for personal privacy and dignity.
3. Select their own preferred provider or physician group from the Highmark Blue Shield Medicare Advantage PPO Network.
4. Expect their provider’s team of health care workers to provide or to help them arrange for all the care that they need
5. Participate in the health care process. If they are unable to fully participate in this discussion, they have the right to name a representative to act on their behalf.
6. Receive enough information to help them make a thoughtful decision before they receive any recommended treatment.
7. Be informed of their diagnosis and treatment plans in terms they understand and participate in decisions involving their medical care.
8. Talk openly with their network provider about appropriate and medically necessary treatment options for their condition, regardless of cost or benefit coverage.
9. Have reasonable access to appropriate medical services.
10. Be provided with complete information about FreedomBlue, including the services it provides, the practitioners who provide care and information on member rights and responsibilities.
11. Confidential health records, except when disclosure is required by law or permitted in writing by you with adequate notice. They have the right to review their medical records with their participating network doctor.
12. Express a complaint and receive an answer to their complaint within a reasonable period of time.
13. Appeal a decision by FreedomBlue if they feel they have been denied a covered service. They may make this appeal directly to FreedomBlue or through a Social Security office or Railroad Retirement Board office (if they are an annuitant).
Continued on next page
The Rights of FreedomBlue Members, Continued
Members’ rights, continued
/ 14. Immediate Quality Improvement Organization review of decisions for hospital discharges, as explained in the Centers for Medicare and Medicaid Services’ “Important Message,” which is given to Medicare members at the time of admission to a hospital, and in the Notice of Discharge and Medicare Appeal Rights given prior to discharge if the member disagrees.15. Call Member Service, Monday through Friday, between 8:00 a.m. and 4:30 p.m. at 1-866-306-1061 (TTY users, please call 1-800-988-0668), to request the following information about Highmark Blue Shield/FreedomBlue:
- How FreedomBlue controls the use of medical services
- The number of appeals and grievances FreedomBlue has received and how these cases were resolved
- How FreedomBlue pays its participating doctors
- The financial condition of the plan
16. Make suggestions about FreedomBlue’s policies on member rights and responsibilities.
The Responsibilities of FreedomBlue Members
Members’ responsibilities
/ FreedomBlue members have the responsibility to…1. Read all FreedomBlue materials carefully and immediately upon enrollment and ask questions when necessary. They have the responsibility to follow the rules of FreedomBlue membership.
2. Identify themselves as a FreedomBlue member when scheduling appointments, seeking consultations with their physician and upon entering any Highmark Blue Shield/Blue Cross of Northeastern Pennsylvania Medicare Advantage PPO Network provider’s office.
3. Treat all Highmark Medicare Advantage PPO Network physicians and personnel respectfully and courteously as their partners in good health care.
4. Communicate openly with the physician they choose. They have the responsibility to develop a physician-patient relationship based on trust and cooperation.
5. Keep scheduled appointments or give adequate notice of delay or cancellation.
6. Ask questions and make certain that they understand the explanations and instructions they are given.
7. Consider the potential consequences if they refuse to comply with treatment plans or recommendations.
8. Pay any applicable physician office, emergency room and prescription drug copayments at the time of service.
9. Pay any applicable FreedomBlue premiums on time.
10. Pay their Medicare Part B premiums (and Part A, if applicable).
11. Help maintain their health and prevent illness and injury.
12. Help FreedomBlue maintain accurate and current medical records by being honest and complete when providing information to health care professionals.
13. Express their opinions, concerns or complaints in a constructive manner to the appropriate people at FreedomBlue.
14. Notify the FreedomBlue Member Service Department, Monday through Friday, between 8:00 a.m. and 4:30 p.m., at 1-866-306-1061 of any changes in their personal situation which may affect the plan’s ability to communicate with them or provide health care to them, including any changes in their address or phone number, any extended trips or vacations, and of their return to the service area from a trip of up to 6 consecutive months. TTY users, please call 1-800-988-0668.
Characteristics of PPO Programs, Including FreedomBlue
Characteristics of PPO programs
/ FreedomBlue shares the major characteristics of most PPO programs.The cornerstone of the program is the network:
· When members receive covered services from network providers, those services are paid at the higher level defined in the benefit contract. (Some services require a copayment or coinsurance even when rendered by a network provider.)
· Members can still receive most covered services from non-network providers, but if they choose to do so, they are responsible for a greater share of the financial responsibility for the services. (In these situations, FreedomBlue reimburses the provider 80% of the Medicare fee schedule for the eligible services after the member has met his or her annual non-network deductible.)
Emergency care, urgent care, renal dialysis
/ Emergency care, urgently needed care and renal dialysis services are exceptions to the rule described above. These services are covered at the higher network level, regardless of where the care is received. Deductible and coinsurance do not apply to emergency care, urgently needed care and renal dialysis services. (Copayment applies, except for dialysis services; for emergency care, the copayment may be waived if the member is admitted as an inpatient for the emergency condition within three days and the admission is authorized.)For more information about emergency care, please see page 13.
Medical Management Requirements: Authorization of Inpatient Admissions
Authorization review
/ Authorization review is the process by which services are evaluated according to criteria for medical necessity and appropriateness – ordinarily before services are rendered, or within 48 hours of the request for an emergency admission.Purpose of authorization review
/ The purpose of authorization review is to determine whether the services being requested are medically necessary and appropriate and are being delivered in the most appropriate setting. Authorization review assists Care and Case Managers in identifying potential candidates for post-discharge case management or the Blues On CallSM condition management program.A provider- driven process
/ The authorization process is provider-driven for all in-network care. This means that it is the provider’s responsibility to obtain authorization for an inpatient admission or any outpatient services requiring this approval. If authorization is required but not obtained, the corresponding claim will be rejected and the member must be held harmless. In order for the claim to be considered for payment, the provider will need to request a retrospective review and submit the applicable medical records. For more information about requesting retrospective review, please see page 21.Inpatient admissions require authorization
/ Authorization is required under FreedomBlue whenever a member is admitted as an inpatient to any of these types of facilities:· Acute-care hospital
· Long-term acute-care hospital
· Rehabilitation hospital
· Mental health or substance abuse treatment facility
· Skilled nursing facility
Continued on next page
Medical Management Requirements: Authorization of Inpatient Admissions, Continued
Maternity is an exception
/ Maternity admissions are an exception to the rule above and do not require authorization. Facilities do need to notify Healthcare Management Services that the admission has occurred so that a case record can be established.
Medical Management Requirements: Transfers