Healthy Blue + Medicare

The Model of Care Training

Annually, a representative from each provider’s practice and/or facility must attest to completing the Special Needs Plans (SNPs) and Model of Care overview.  At the end of the training, an attestation form must be completed by the representative attesting that training has been completed.

Model of Care Training  Model of Care Attestation Form

Should you encounter an issue with completing the attestation form online after reviewing the Model of Care training, you may print a copy of the form (pdf), complete all required information and fax to 919-765-7109 or you may return the attestation via e-mail to DSNP_providerattestations@bcbsnc.com. 

Availity Training

All claims for Healthy Blue + Medicare members are required to be filed through Availity.  We have provided a claims filing tutorial for Availity should you need assistance. Please do not file any claims through Blue e, the Blue Cross and Blue Shield of North Carolina claims filing portal.

Go to Availity

Forms

Below are the essential forms that are required to be completed prior to rendering services such as general pre-certification forms, behavioral health treatment and refund requests.

• Behavioral Health Concurrent Review Fax Form (pdf)
  Please complete for any concurrent review
• Behavioral Health Discharge Note (pdf)
  Form provides information when member will be discharged from behavioral health treatment
• Electroconvulsive Therapy Prior Authorization Request (pdf)
  ECT services require prior authorization and form must be submitted prior to rendering treatment
• General Precertification Request (pdf)
  Form can be used to request prior authorization for inpatient admissions
• Initial Note Review (pdf)
  Request for an initial case for behavioral health
• Mental Health Outpatient Treatment Report (pdf)
  Services require prior authorization and form must be completed prior to rendering treatment
• Neuropsychological Testing (pdf)
  Request for Authorization-services require prior authorization and form must be submitted prior to rendering treatment
• Overpayment Refund Notification Form (pdf)
  Please complete this form when refunding money and include all necessary documentation
• Psychological Testing Request for Authorization (pdf)
  Services require prior authorization and form must be completed prior to rendering treatment
• Recoupment Authorization Form (pdf)
  Please complete this form and mail with supporting documentation authorizing adjustments to be offset/recouped from future claims payments, do not enclose a check for the amount to be refunded when submitting this form.
• Transcranial Magnetic Stimulation (TMS) Request Form (pdf)
  Please complete this form in its entirety and submit for prior review when rendering TMS services.

Resources​

• Overview of Medicaid with Healthy Blue® and Medicare Advantage with Healthy Blue + Medicare ^SM (HMO D-SNP) (pdf)
  Blue Cross NC has developed a Healthy Blue and Healthy Blue + Medicare overview highlighting key points about each product. This overview provides important details about each product, the differences between each product and will assist providers in administering both products for our members appropriately.
• Availity Portal Overview (pdf)
• Blue Cross NC and Anthem Collaboration
• Clinical Criteria Updates November 2022 Healthy Blue + Medicare (HMO D-SNP) (pdf)
• Electronic Data Interchange Overview (pdf)
• How to Navigate Patient360 through the Availity Portal (pdf)
• Healthy Blue + Medicare D-SNP Supplemental Guide (pdf)
• Improving the Patient Experience (pdf)
• Medical Policies and Clinical UM Guidelines – Portal | Instructions
• Medical Policies and Clinical Utilization Management Guidelines Update (pdf)
• Medical Step Therapy - Rituxan Agents (pdf)
• Medicare Medical Precertification Expansion (pdf)
• Medicare Part B Precert Expansion Imjudo, Pedmark, Tecvayli, Tzield, Vegzelma (pdf)
• Medicare Risk Adjustment Provider Documentation and Coding Guide (pdf)
• MCG Care Guidelines 26th Edition
• Pharmacy Clinical Criteria
  Clinical criteria documents for all injectable, infused or implanted prescription drugs and therapies covered under the Healthy Blue + Medicare medical benefit (Part C).
• Providing a Superb Patient Experience (pdf)
• Remittance Inquiry Reference Guide (pdf)
• Somatus is your Resource for Kidney Care Management (pdf)

Reimbursement Policies

• Claims Timely Filing (pdf)
• Code and Clinical Editing Guidelines (pdf)
• Corrected Claims (pdf)
• Diagnosis-Related Group (DRG) Inpatient Facility Transfers (pdf)
• Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (pdf)
• Drug Injectable Limits (pdf)
• Eligible Billed Charges (pdf)
• Emergency Department: Leveling of Evaluation and Management Services (pdf)
• Emergency Services: Nonparticipating Providers and Facilities (pdf)
• Facility Take-Home DME and Medical Supplies (pdf)
• Inpatient Readmissions (pdf)
• Maximum Units Per Day (pdf)
• Modifiers 25 and 57 (pdf)
• Modifier 63 (pdf)
• Modifier 66: Surgical Teams (pdf)
• Modifier 76: Repeat Procedure by the Same Physician (pdf)
• Modifier 91 (pdf)
• Modifier Usage (pdf)
• Multiple Delivery Services (pdf)
• Multiple Procedure Payment Reduction (pdf)
• Multiple Radiology Payment Reduction (pdf)
• Nurse Practitioner and Physician Assistant Services (pdf)
• Professional Anesthesia Services (pdf)
• Prosthetic and Orthotic Devices (pdf)
• Reduced and Discontinued Policies (pdf)
• Reimbursement Policies Disclaimer (pdf)
• Reimbursement Policies Overview (pdf)
• Sterilization (pdf)

Sample ID cards

Contact Information

We have provided you with a list of useful contacts.