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Providers

Frequently asked questions

  

Blue Medicare

Yes. The Medicare Advantage member appeal process as defined by Medicare is not changing. Providers can still appeal on behalf of the member in accordance with 42 CFR 422.578.

Call 888-296-9790 and a Blue Cross NC representative can assist you.

The right to appeal is available to providers for disputes of post-adjudicated claims related to medical necessity, billing/coding, and no pre-authorization for an inpatient stay. Provider appeals may be submitted without written consent from the member, but must be submitted in writing from the provider. 

Level I Post-Service Provider Appeals for claim denials related to billing/coding, cosmetic, experimental/investigational, medical necessity, and no pre-authorization for inpatient stay are handled by Blue Cross NC and are available to all providers. 

Claim denials for no authorization for inpatient stay are eligible for a Level I Post-Service Provider Appeal.

An appeal form is available for most member plan types. Go to Claims, Appeals and Inquiries page, find the member's plan type and then select File Appeal. You can find the corresponding appeal form on the plan type Appeals and Inquiries page.

Providers will have 90 calendar days from the claim adjudication date to submit a Level I post-service provider appeal.

The member appeal will take precedence and the provider appeal will be closed. The provider will receive a letter notifying the provider that their case has been closed because the member has filed an appeal.

Find required forms, instructions and deadlines for filing appeals on the Claims, Appeals and Inquiries page.

HIPAA information

The provisions, developed by the US Department of Health and Human Services (HHS), establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. They also address the security and privacy of protected health information. These standards are intended to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.

The provisions cover the following:

  •  Electronic transactions, code sets and identifiers (effective October 16, 2003)
  •  Privacy of protected health information (effective April 14, 2003) 
  •  Security (effective March 2005)

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA affects almost the entire health care industry, including employers. For health plans, providers and health care clearinghouses, the critical portions of the act are the Administrative Simplification provisions, which include new standards for electronic transactions that took effect Oct. 16, 2003, as well as regulations on the privacy and security of personal health care information.

Payers, healthcare providers and clearinghouses must use specified standards when exchanging these data types in electronic form:

  •  Claims and claim status
  •  Remittances (Notice of Payment or Explanation of Payment)
  •  Eligibility
  •  Authorizations and referrals

HIPAA is a federally mandated law. If providers do not make an effort to become compliant, they will be subject to penalties.

HIPAA transition

Yes. The Blue Cross NC Companion Guide to EDI Transactions documents any assumptions, conventions, or data issues that may be specific to Blue Cross NC business process when implementing the HIPAA ASC X12N Implementation Guides. The Blue Cross NC Companion Guide consists of one chapter for each transaction type, an introductory chapter for information applicable to all transmissions, and appendices that include Blue Cross NC business edits for health care claims. The Introduction to the Blue Cross NC Companion Guide to EDI Transactions outlines:

  • Blue Cross NC business process issues applicable to all transactions
  • Interchange Control and Functional Group details
  • Connectivity
  • Reporting Tools (Acknowledgements and Error Reports)

 

The Blue Cross NC Companion Guide to EDI Transactions is available as PDF files on the HIPAA information page.

Blue Cross NC accepts any HIPAA compliant data value within a transaction. However, Blue Cross NC may only process certain values within a given data set. The Blue Cross NC Companion Guide transaction chapters specify those data elements that are required for Blue Cross NC processing. Blue Cross NC believes this is consistent with the regulations of HIPAA, as illustrated by the following portion of the 837 Institutional Health Care Claim Implementation Guide:

837 Health Care Claim Implementation Guide - Section 1.3:

"Payers are required by law to have the capability to send/receive all HIPAA transactions. However, that does not mean that the payer is required to bring that data into their adjudication system. The payer, acting in accordance with policy and contractual agreements, can ignore data within the 837 data set. In light of this, it is permissible for trading partners to specify a subset of an implementation guide as data they are able to 'process' or act upon most efficiently. It behooves trading partners to be clear about the specific data within the 837 they require or would prefer to have in order to efficiently adjudicate a claim."

EDI requirements

If you are a company that sends transactions on behalf of health care providers or you are a large provider institution that submits transactions on behalf of multiple provider groups, you will need to identify each group Blue Cross NC Provider ID for which you transmit files. However, you can send all group provider identifiers for which your organization is responsible on one form, using additional sheets of paper if necessary. However, separate forms must be submitted for 837 Institutional Provider Identifiers and 837 Professional Provider Identifiers.

No. However, a newly credentialed practitioner should be assigned a Blue Cross NC Provider Identifier Number by Network Management, another department of Blue Cross NC. Contact your local Network Management field consultant for more information.

The TPA outlines the roles and responsibilities that bind both Blue Cross NC and its trading partner, to ensure secure electronic transmissions. A TPA is not required by HIPAA, but the ASC Insurance Subcommittee that was charged with developing the Implementation Guides for EDI transactions strongly recommends that trading partners have binding agreements to provide security and assurance in the transfer of electronic information (See Section 1.1.1 of any ASC X12 Implementation Guide). Blue Cross NC has made a business decision to make trading partner agreements a requirement for EDI transmission based on this recommendation.

Blue Cross NC requires the execution of its own TPA with all entities that are sending us direct transmissions. The Blue Cross NC Trading Partner Agreement is comprehensive and should address any issues or legal concerns of our trading partners.

Direct Senders of electronic transactions will need to do the following:

  • Complete a copy of the Blue Cross NC Trading Partner Agreement (TPA), available on the HIPAA information page. You need to complete a TPA even if you do not need to test.
  • Return an original copy of the TPA, signed by authorized personnel, to Blue Cross NC EDI Services (see Trading Partner Agreement Instructions online for more details).
  • Complete an Electronic Connectivity Request (ECR) form for each type of transaction you want to transmit. These ECR forms are available on the HIPAA information page.

Indirect Senders who transmit electronic transactions to Blue Cross NC via another party (billing service, clearinghouse, or service bureau) will need to do the following:

Complete ECR forms for each type of transaction you want to submit or receive. These ECR forms are available on the HIPAA information page and may be completed and submitted on your behalf by your clearinghouse or service bureau.

You can call the eSolutions HelpDesk at 888-333-8594 to verify the status on your Trading Partner Agreement or ECR.

Right now there is only one version of HIPAA-compliant transactions in release for transmission. However, as new versions are approved in the future, there will be multiple version options available. Each version will have distinct requirements, so it will be important to identify which version you are transmitting on your ECR form.

Edits and reporting tools

The HIPAA compliant 997 and TA1 Acknowledgments, as well as the Blue Cross NC Claims Audit Report, are returned to the sender of the transmission. Providers using a clearinghouse or billing service are not likely to use the 997 and TA1. However, all providers should have access to their Blue Cross NC Claims Audit Report. Most clearinghouses collate the proprietary reports of payers for each of their providers and return the reports to the provider in some format, if not the original. If you have not been receiving the Blue Cross NC Claims Audit Report from your clearinghouse, contact them and inquire as to why. It is critical for all providers to use their Claims Audit Report to correct claims that have errors and resubmit those claims electronically.

Providers should also discuss with their clearinghouse how they will be informed when a negative TA1 or 997, involving their data, is received.

Implementation Guide edits address issues such as the presence of required fields or fields required under certain conditions, the validation of data structure (e.g. alpha-numeric requirements, field length), and the correct usage of medical and non-medical code sets. Implementation Guide edits are identified through the TA1 or 997 Acknowledgment transactions.

Blue Cross NC business edits address only those data elements that are required for business processing. For health care claims, our business edits are defined in the context of the 837 transactions in both Chapters 1 and 2 of the Blue Cross NC Companion Guide to EDI Transactions. The Blue Cross NC business edits are also listed in Appendices B and C of the Blue Cross NC Companion Guide to EDI Transactions. Business edits are identified by either the Blue Cross NC Claims Audit Report (for 837 Claims filings) or by the paired transaction to a 270, 276, or 278. Those transmitting 834 files are notified of business edits via phone or email.

The TA1 Acknowledgment is returned immediately upon receipt of the transmission. Senders should expect to see the TA1 within 5 minutes. The 997 Acknowledgment is also generated immediately, but because the 997 can vary in length, it may take slightly longer. The Claims Audit Report is generated nightly, reflecting all claims that were transmitted by 4:45 p.m. that business day, and received by senders the next business day by 8:00 a.m.

Providers need to speak to their vendor/clearinghouse about this issue. Blue Cross NC is not providing alternative reporting tools to the TA1 and 997 Acknowledgments.

Yes. Both the 997 and TA1 Acknowledgment include the acronym "ACK" in the file naming convention so that these files are immediately recognizable. In addition, transaction files include the transaction number in the file name. The 271, 277, 278, and 835 include those numbers in the file name. As in the past, senders receive their Batch IDs when they receive the EDI Production Services Notification Letter confirming their connectivity and readiness date.

Blue Cross NC has elected to use the TA1 and 997 Acknowledgment transactions to confirm transmissions. These reporting tools are in addition to the traditional Claims Audit Reports that providers are accustomed to receiving for claims submissions. Detailed information about the TA1 and 997 is contained in each transaction chapter of the Blue Cross NC Companion Guide to EDI Transactions.

Health care claims and COB

Generally, the percentage of claims requiring additional medical notes for processing is small. When such claims appear, providers are contacted, via letter, when that information is needed. Providers who want to send additional medical notes information should use the NTE Segment of the 2300 Loop in the 837 electronic claim. Providers should NOT send unsolicited medical notes on paper as they cannot be attached to the electronic claim.

Blue Cross NC requires that secondary claims be filed after primary claims have been processed and posted to the provider's practice management system. The 837 Health Care Transactions provide for COB claims data, and secondary claims should be submitted by batch transaction, just as primary claims are submitted. The 2320 Loop of the 837 contains all COB (Coordination of Benefits) information.

Yes.

No. If the secondary claim is filed electronically in the 837 format and includes the primary payment information, you do not need to supply a paper EOB.

Yes, WebMD must complete the Blue Cross NC Electronic Connectivity Request (ECR) form with the provider's identifying information and authorized signature before electronic set-up can be completed.

Blue Cross NC invokes security validation edits to ensure that only authorized trading partners and providers are exchanging data with Blue Cross NC. Security validation takes place at both the ISA (Interchange) and GS (Functional Group) Levels of the transmission, as well as the ST (Transaction Set) Level of the transmission.

What portion of the transmission gets rejected depends upon where the violation occurs. If the violation is in the ISA, the entire transmission fails. If it is in the GS portion, the entire Functional Group fails. If a security violation occurs within the Transaction Set, all claims/inquiries associated with the same Provider Identifier that could not be validated fail. See individual chapters of the Blue Cross NC Companion Guide to EDI Transactions for more information.

Yes. Providers should submit State Health Plan claims as they would any other.

Mental health claims should be filed directly with Blue Cross NC. Claims for Blue Medicare and commercial HMO members for dates of service with a start date prior to January 1, 2020 should be submitted to Magellan. Call the provider Blue line with questions at 800-214-4844.

In the past, Blue Cross NC manually revised many paper and electronic claims containing faulty data when the error involved identifiable data elements that we were able to correct. However, given changes mandated by HIPAA, Blue Cross NC no longer allows the manual changing of identification numbers, dates of service, place of service, diagnosis codes, procedure codes, or provider numbers. Claims submitted with these errors will be subject to all HIPAA Implementation Guide edits and Blue Cross NC business edits and will be returned to the provider for correction.

No. Taxonomy codes are not required for Blue Cross NC adjudication. The PRV segment (Loop 2000A) is not required for Blue Cross NC processing.

Business edits are specific to each payer. Blue Cross NC provides tables with its Business Edit Codes in Appendices B and C of the Blue Cross NC Companion Guide to EDI Transactions.

Claim Status Codes, which include codes for denials, exist for the 835 Remittance/Payment Advice (CLP Segment) and the 277 Claim Status Response (STC Segment). These codes are common to all payers.

Yes. E-Codes are accepted but not required for Blue Cross NC processing.

Blue Cross NC cannot over-rule any requirement from the HIPAA Implementation Guides (IG). If an Implementation Guide states that data is required, it must be included in the transaction. In the example given, transaction would be rejected prior to any Blue Cross NC processing because it would not pass the Implementation Guide edits.

Providers should work with their software vendors and business personnel to ensure that required data is being collected and maintained in their practice management systems.

Blue Cross NC now requires that membership identification numbers be submitted exactly as they appear on the Membership ID Card. Membership Identification Numbers for Blue Card and Federal Employee Plan members may or may not include suffixes. Transactions for these plan members are routed through Blue Exchange. You will continue to see a request for the exact membership ID numbers if the number cannot be validated.

If the HIPAA Implementation Guide requires a segment or element, you must include it in the transaction, even if Blue Cross NC does not need this data to process the claim. Include the service codes when filing your 837 Professional Claims to ensure your transaction passes the Implementation Guide edits.

Blue e

Blue Cross NC continues to provide Blue e and RealMed services and support them.

The error correction functionality of Blue e is not available for claims submitted in the HIPAA-compliant 837 format, but will be available for those claims submitted on Blue e or in batch local proprietary format. Blue e claim correction functionality is being removed in the HIPAA compliant format to encourage providers to make corrections to claims on their practice management systems and resubmit claims in electronic batch.

Blue e services are available for both the local proprietary format and HIPAA compliant transactions. Blue e is available for direct data entry of claims, claim correction, and inquiries in the Blue Cross NC local proprietary format and will continue to be available for as long as the CMS contingency plan is in place and the local proprietary format can be accepted.

Blue e is available for eligibility inquiries and inquiries about 837 claims submitted in batch to Blue Cross NC; however, the claims correction functionality on Blue e is not available for HIPAA compliant 837 claims.

Batch 837 Health Care Claims can no longer be corrected on Blue e. A new error listing on Blue e identifies of the 837 errors - the 837 Claim Denial Listing. Providers should correct claims in error on their practice management systems and resubmit those claims in a batch 837 Health Care Claim transactions. Batch claims are processed daily in the evening. As soon as the corrected claims are processed and successfully adjudicated, they are dropped from the Blue e Error Listing.

Yes, both claim status and eligibility information for out-of-state claims and members are available. Blue e transmits your inquiries to the Blue Cross and Blue Shield home plan of your patient and returns their response.

Blue Card

Responses from Blue Exchange are in 'real-time' – usually within seconds, depending on the response time of the plan to which it was sent. Users can access the Summary Results pages to retrieve responses from other Blue plans.

HIPAA Privacy regulations have demanded greater care in the protection of customers' Personal Health Information (PHI). As a consequence, membership identification numbers, along with other member data, submitted for inquiries or claims must match Blue Cross NC system data before they can be accepted and processed. Different Blue plans have different prefix and/or suffix formats (or none at all). If the submitted membership ID exactly matches that of the ID number as presented on the membership ID card, the membership ID number will be recognized.

Blue Exchange, the data management system shared with Blue Cross and Blue Shield plans around the country, has been available for HIPAA-compliant transactions since August of 2003. Transactions that have been routed through Blue Exchange are already receiving acknowledgments and responses.

Trading partners, vendors and clearinghouses

Yes. However, you must complete an 835 Electronic Connectivity Request form if the vendor handling the 835 is different from the vendor handling your 837 Claims.

Blue Cross NC cannot tell you if your clearinghouse or billing service has begun testing. Contact them directly.

Blue Cross NC will consider new suppliers based upon business needs, existing contractual relationships and supplier product and service offerings.

Contract duration varies. When a contract is up for renewal, Blue Cross NC may invite qualified suppliers to participate in a bid opportunity. Blue Cross NC reserves the right to continue pre-existing relationships without conducting new bids.

No. Only direct senders of transmissions need to test with Blue Cross NC. If you are using a clearinghouse billing service, or software from a vendor that has tested, you do not need to test with Blue Cross NC.

Certification means your organization has been reviewed and confirmed by a third-party certifying agency as a diverse-owned business. Suppliers are responsible for acquiring and maintaining valid certification.

All paired transactions (the 271, 277, 278-11) are returned to the sender of the initiating transaction (the 270, 276, 278-13). The 835 is returned either to the sender of the 837 OR to the entity identified on the 835 Electronic Connectivity Request form if it should be returned to an entity other than that which transmitted the 837.

Credentialing

The database can by accessed via the internet at caqh.org. The provider will use a personal ID and password to directly access the database over the internet. Providers may transmit the completed application electronically, or if they do not have Internet access, may call the CAQH Help Desk at 888-599-1771 and request an application to be sent by mail. The provider simply completes the paper copy and faxes it back to a toll-free number.

Physicians and other health care providers submit their credentialing information to the system database online, or via fax. Organizations requiring provider credentials access the system for the information they require. The CAQH database administrator contacts physicians and other health care providers quarterly to update or validate the information via email or fax, and will provide information only to organizations the provider has authorized. Plans will automatically be notified of any updates or changes to provider information.

There are no fees to physicians and other health care providers to use the database. Participating CAQH health plans and health care organizations pay the costs of developing and maintaining the system.

CAQH worked closely with health plans, physicians, physician professional associations, and accreditation organizations in the development of the system to build an approach that meets the needs of most health plans and other healthcare organizations involved in the credentialing process.

The CAQH system is secure so that only health care organizations authorized by a physician or other health care provider have access. Providers have access only to their own data – not that of others.

The Council for Affordable Quality Healthcare is a not-for-profit collaborative alliance of the nation's leading health plans and networks, including Blue Cross NC. CAQH's mission is the improvement of healthcare access and quality for patients and the reduction of the administrative burden for healthcare providers and their office staff members.

The system is a national provider credentialing application initiative from the Council for Affordable Quality Healthcare. The easy-to-use, streamlined database is the single repository of participating health plans for healthcare provider information, alleviating the need for physicians and other healthcare providers to complete and submit many different credentialing forms for multiple health plans, hospitals and other healthcare organizations. More than 300,000 providers are now reducing paperwork and administrative costs through the UCD.

The CAQH Universal Credentialing DataSource is designed make the credentialing process easier for providers by gathering data in a single repository that may be accessed by participating health plans and other healthcare organizations. The DataSource enables providers to easily update their information.

More information about the CAQH Universal Credentialing DataSource is available on the CAQH Website at caqh.org or by calling 888-600-9802.

All participating Blue Cross NC providers are eligible to use the CAQH Universal Credentialing DataSource.

Blue Cross NC works to ensure that the healthcare providers under contract with us are adequately trained, certified and/or licensed to provide care. One of the most integral parts of the credentialing process is the collection and verification of vital data from the provider regarding his or her education, training, experience, practice history, location, disclosure of any issues impacting their ability to provide care, and other background information. Credentialing involves paperwork and administrative time. The CAQH Universal Credentialing DataSource greatly reduces the amount of administrative time required in this process for physicians and other health care providers.

A typical physician or other healthcare provider contracts with as many as 10 to 20 healthcare organizations, each of which requires a time-consuming credentialing application. The amount of time associated with the credentialing application process is dramatically reduced through the use of a standard application submitted to a single source. In short, this system means one doctor, one application, and one secure database for all participating health plans. It represents a move from paperwork to more efficient online information gathering.

Specialty Pharmacy Network

Specialty medications are most commonly used for chronic diseases such as rheumatoid arthritis and multiple sclerosis. These drugs are generally high-cost drugs, ranging from approximately $6,000 to $350,000 per patient, per year. Most specialty drugs are injectable and require special handling and administration. Specialty drugs are not limited to a specific copayment or coinsurance tier, but can be found in all formulary tier levels.

In recent years, the use of specialty drugs has increased significantly and along with that, the cost of covering those drugs. To ensure that specialty drugs remain affordable for our members, Blue Cross NC has contracted with a new network of pharmacies committed to providing better pricing on specialty medications.

With this specialty retail drug network, there may be a limited number of pharmacies dispensing these medications. Since some pharmacies may choose not to participate in the specialty drug network, you may need to transfer your prescription for specialty drugs to a participating local pharmacy or mail order pharmacy. Please refer to the pharmacy list.

You can transfer any remaining refills on a prescription from your current pharmacy to a participating specialty drug network pharmacy by providing your prescription information to the new pharmacy. The new pharmacy will either transfer the prescription or obtain a new prescription for you by contacting your physician.

No, specialty medications are all name brands and not currently available as a generic.

The majority of specialty medications are covered under your medical benefits and administered in a medical office; however, some specialty medications may be oral or self-administered and are covered by your pharmacy benefits. Only the specialty medications covered by your pharmacy benefits will be included in this network.

If you have a health savings account or coinsurance plan, when you visit a new network pharmacy, your costs may actually be lower. If you have a copayment plan, you will not see an increase in your out-of-pocket cost as long as you visit a pharmacy participating in the specialty drug network.

Yes. When new medications become available in the therapeutic classes, they will be added to the list. Please refer to the specialty medications list.

You may want to consider mail-order delivery of your specialty medication. There are many specialty pharmacies available that will mail your prescription to your home, under refrigeration, if necessary, and will also provide specialty services such as adherence monitoring and refill reminders.

Blue Cross NC members who currently have pharmacy benefits and use specialty drugs must use the specialty drug network in order for their prescriptions to be covered. This does not impact Blue Medicare Rx℠, North Carolina State Health Plan, or Federal Employee Program® (FEP) members.

Additional pharmacies may join the network at any time. Please continue to refer to the pharmacy list to check for updates.

Provider appeals

Yes. The member appeal process is not changing.

No, there is no right for providers to appeal a denial for no prior review. These denials are considered administrative and are not eligible for review.

The pre-service review process is not changing. If a pre-service request is denied, you can contact American Imaging Management (AIM), Member Health Partnership Operations (MHPO), or Value Options for a pre-service Provider Courtesy Review (PCR). If the PCR is denied, the member can request a Level I pre-service appeal of the decision. If the service is performed and the claim is denied, both the member and the provider have the right to request a post-service Level I appeal. If the service is performed and is denied as not medically necessary, the member and the provider both have appeal rights. If the service is performed and the claim denies for no prior review and charges are provider liability, neither the member nor the provider may appeal as this is a contractual denial.

In most cases, the Level I Provider Appeal is replacing the post-service Provider Courtesy Review. The only exception is that Provider Courtesy Reviews will be available for State PPO Pharmacy PA/QL (prior approval/quantity limit) denials.

Call 800-214-4844 and a Blue Cross NC representative can assist you.

The right to appeal will be extended to providers for disputes of post-adjudicated claims related to medical necessity, billing/coding, and no pre-authorization for an inpatient stay. Provider appeals may be submitted without written consent from the member, but must be submitted in writing from the provider.

Level I Provider Appeals for billing disputes, medical necessity denials, and denials for no pre-authorization for an inpatient stay are handled by Blue Cross NC and available to all providers.

An appeal form is available for most member plan types. Go to the Claims, appeals and inquiries page, find the member's plan type and then select File Appeal. You can find the corresponding appeal form on the plan type Appeals and Inquiries page. Complete the form and fax it to one of the following numbers:

Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Billing/Coding Dispute.

Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Medical Necessity Appeal.

The member appeal will take precedence and the provider appeal will be closed. You will receive a letter notifying you that your case has been closed because the member has filed an appeal. Later, when a decision has been rendered, you will receive a copy of the member appeal decision letter.

An appeal form is available for most member plan types. Go to the Claims, appeals and inquiries page, find the member's plan type and then select File Appeal. You can find the corresponding appeal form on the plan type Appeals and Inquiries page. 

Post-service Blue Medicare appeals for non-contract providers

Yes. The Medicare Advantage member appeal process as defined by Medicare is not changing.

Yes, but not with Blue Cross NC. If we uphold the denial we will forward the appeal on to MAXIMUS, Federal Services, Inc. (IRE) and notify the appellant of the appeal rights.

Call 888-296-9790 and a Blue Cross NC representative can assist you.

It is not required by CMS for a non-contract provider to submit an appeal form. Non-contract providers should include the Waiver of Liability statement, documentation such as a copy of the original claim, denial notice, and any clinical records that support the appeal. 

The appeal and/or forms can be mailed to: 
Blue Medicare HMO (or PPO
Attn: Non Contract Appeals and Grievances 
P.O. Box 17509 
Winston-Salem, NC 27116-7509

Non-contact providers will have 60 calendar days from the date of the EOP, notice of the organization determination, to submit a Post-Service appeal. If the non-contracted provider does not complete the Waiver of Liability statement within the appeal time frame, Blue Cross NC will forward the case to the Independent Review Entity (IRE) with a request for dismissal.

If Blue Cross NC does not receive the form, Blue Cross NC cannot accept the appeal. Instead, the "case file" will be reviewed and submitted to MAXIMUS, Federal Services Inc., (IRE) for dismissal. However, the plan will make reasonable attempts to obtain the form in the appeal timeframe prior to sending to MAXIMUS.

MAXIMUS, Federal Services, Inc. is the independent review entity that Medicare uses to review cases to make sure that the right decision was made.

A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver of Liability statement, which states that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal. The appeal must be in writing. 

A third-party vendor cannot file on behalf of the non-contract provider. The non-contract provider must file on his or her behalf.

The purpose of this statement is to ensure that the member will not be held financially liable if the provider loses the appeal. The signed Waiver of Liability document must be included in the appeal file submitted to Blue Cross and Blue Shield of North Carolina (Blue Cross NC). If it is not received within the appeal timeframe, Blue Cross NC will forward the appeal request on to the Independent Review Entity (IRE), MAXIMUS, Federal Services, Inc. for dismissal. 

BlueHPN

If your practice is a BlueHPN℠ Provider, all providers under the practice are considered participating under the BlueHPN℠ product. Please contact your office manager or contracting manager / representative. You may also use our Find Care tool or contact the Provider Blue Line℠ at 800-214-4844.

BlueHPN health care providers are measured individually and at an aggregate network level. Quality is measured across all aspects of care delivery (e.g., inpatient, outpatient) and within each provider type (e.g., primary care, specialist, hospital or health system). This approach was established because:

  • Individual performance results allow us to identify opportunities for improvement and to recognize higher-value care
  • Aggregating quality results allows us to understand BlueHPN market level performance in comparison to our BlueCard PPO healthcare provider population

Processes are already in place to collect and submit Healthcare Effectiveness Data and Information Set (HEDIS) and Hospital Compare quality measure data, which is some of the information we assess to measure quality. National quality measures from the National Committee for Quality Assurance (NCQA), HEDIS and the Centers for Medicare and Medicaid Services (CMS) Hospital Compare were primarily used. There is no current need for additional data to be submitted to plans at this time.

HEDIS is one of the most widely used set of healthcare performance measures in the United States. HEDIS includes 95 measures across seven domains of care. NCQA has expanded the size and scope of HEDIS to include measures for physicians, PPOs and other organizations.

Hospital Compare (Care Compare), on the other hand, was created through the efforts of CMS and has information about the quality of care at over 4,000 Medicare-certified hospitals across the country. The information on Hospital Compare helps patients make decisions about where to get their healthcare and encourages hospitals to improve the quality of care they provide.

We select quality measures that address key healthcare challenges in each local market, prioritizing measures that align with community health disparities, or those that incentivize better performance in areas that address local needs or challenges. For example, diabetes management might be a critical quality indicator in one community while improving immunization adherence is higher priority in another.

When selecting national measures for BlueHPN, we identified measures that:

  • Are aligned with industry-recognized standards, such as the Catalyst for Payment Reform
  • Are most commonly used to establish healthcare provider accountability for better patient outcomes
  • Closed clinical care gaps, impact longevity and quality of life and/or lower costs
  • Spanned care settings and provider types (primary care, specialists and hospitals) to provide a more holistic view of clinical quality performance
  • Accounted for regulatory and/or state mandates
  • Created a foundation and framework for continuous improvement

BlueHPN patients can easily be identified by looking at their Blue Cross NC member ID card. The Blue High Performance Network name will be prominently displayed on the front of the member ID card, along with the “BlueHPN in a suitcase” logo. This “BlueHPN in a suitcase” logo indicates that PPO rates apply unless your provider contract indicates otherwise. If you don’t see the Blue High Performance Network name or the “BlueHPN in a suitcase” logo on the front of the member ID card, then the patient is not in BlueHPN.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) contracts with health care providers to be in BlueHPN. Your office manager or contracting manager / representative will have information on the networks you participate in, including BlueHPN.

As a BlueHPN health care provider, your practice will appear on our online “Find Care” tool when a provider search is done in your geographic area. If you would like to confirm this, we can instruct you on how to conduct a search using the “Find Care” tool, or please reference the instructions below. Please contact the Provider Blue Line at 800-214-4844 if you need additional assistance.

  • Click the "Look up a Doctor or Drug" button from our Find Care page.
  • Log in to Blue Connect or browse as a guest.
  • Select the "Doctor or facility" button.
  • Once redirected, choose the Blue High Performance Network plan from the drop-down Network box at the top of the page.
    • Once the plan has been selected, select the care you need.
    • You also have the option of a keyword search in the Search field.
    • If using the search field, type your practice or provider name in the search field.
    • Once you have selected your practice or provider name that meets your search, click on the provider name to find more details on the profile, and verify BlueHPN par status under the plans accepted section. If not using the search field, the steps below outline directions to browse by Medical Specialty.
    • Click the appropriate item that suits your practice (e.g., Medical Specialties).
    • Click the appropriate medical specialty (e.g., Specialist).
    • Click the appropriate specialist category (e.g., Dermatology). Each item represents a group of certain types of providers.
    • Select the item that appropriately suits your needs. A listing of the selected specialists appears. This list can span multiple pages.
    • Once you have selected the type of provider that fits your search, click on the provider to find more details on their profiles, and verify BlueHPN par status under the plans accepted section.

In the near future, score cards will be created and discussed with providers.

We deliberately designed BlueHPN to evolve over time so it will reflect behavior change and account for improved health care provider performance to focus more on outcome measures. As we evaluate the performance of BlueHPN health care providers, our selection criteria and measurement approach will be refined to ensure the network continues to improve. We’re committed to working with you to continue influencing care quality and affordability. Our data sharing philosophy and collaborative partnerships give providers like you the insight needed to understand the path toward improvement.

BlueHPN is currently closed to network additions. When the anchoring health systems and Blue Cross NC developed these networks, we did an intensive analysis of network adequacy, accessibility, and marketability, incorporating both CMS and NCDOI guidelines. We review network adequacy for each product annually. If you have further questions or concerns, please call Provider Blue Line at 800-214-4844.

If you are a Blue Distinction Specialty Care (BDSC) or Total Care designated healthcare provider and have a signed agreement to participate in BlueHPN, you are considered a BDSC and/or Total Care Designated Health Care provider. Please contact the Provider Blue Line at 800-214-4844 if you have any further questions.

This will depend upon whether BlueHPN patients are included in the value-based contract you or your organization has with Blue Cross NC. Please contact your Blue Cross NC contracting representative to confirm.

We believe greater value can be achieved by working with healthcare providers to elevate the level of care delivered to patients.  A “one-size-fits-all” application of a quality threshold does not account for variation in local healthcare dynamics, appropriateness, and evolving population health priorities. Quality performance requirements for local healthcare provider participation in BlueHPN are determined by evaluating against local, regional, state and/or national benchmarks. Our efforts in this area will continue to evolve.

Please contact the Provider Blue Line at 800-214-4844 to ensure that we have all the information needed from you for an accurate display on the online “Find Care” tool.

It is essential to identify specialists that are in BlueHPN using the “Find Care” tool before making a recommendation to your patient. This is meant to avoid having your patient pay unexpected out-of-pocket costs. If you cannot find an appropriate specialist within BlueHPN to treat your patient's condition, contact the Provider Blue Line at 800-214-4844 as there are exceptions to make sure your BlueHPN patients get the care they need. This is always our priority.

Please contact Blue Cross NC by using the Provider Blue Line at 800-214-4844. There are exceptions to make sure your BlueHPN patients get the care they need. Naturally, our priority is the health of our members.

In general, the same procedures apply for both BlueHPN and BlueCard PPO patients. For example, you will check eligibility and benefits, conduct pre-service review, and submit claims using the same contacts and procedures as you do today. One thing to keep in mind, BlueHPN members have limited out-of-network benefits.

The measures that organizations will be measured on are below. They include both national measures and Blue Cross NC locally selected measures.

Quality CategoryNational Quality Core MeasureNational Quality Data ScoreNC Quality Local MeasureBlue Cross NC Local Quality Measure

1. Appropriate Care

Reduces healthcare waste and prevents patient harm

Asthma Medication RatioNCQA HEDISMedication Management in People with Asthma (75%)NCQA HEDIS
Use of Imaging Studies for Low Back PainNCQA HEDISAvoidance of Antibiotic Treatment in Adults with Acute BronchitisNCQA HEDIS

2. Best Practice Adherence

Uses evidence-based medicine

Elective DeliveryCMS Hospital Compare (Care Compare)Controlling High Blood PressureNCQA HEDIS
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence TreatmentNCQA HEDISPharmacotherapy Management COPD Exacerbation (PCE)-BronchodilatorNCQA HEDIS

3. Better Health Management

Focuses on preventing illness and better managing chronic conditions

Breast Cancer ScreeningNCQA HEDISChild and Adolescent Well-Care Visits (AWC)NCQA HEDIS
Statin Therapy for Patients with Cardiovascular DiseaseNCQA HEDISColorectal Cancer ScreeningNCQA HEDIS

4. Improved Outcomes

To improve the effectiveness of care delivered

Hospital-Wide All-Cause Unplanned Readmission MeasureCMS Hospital Compare (Care Compare)Persistence of Beta-Blocker Treatment after a Heart AttackNCQA HEDIS
Methicillin-resistant Staphylococcus Aureus (MRSA) Blood InfectionsCMS Hospital Compare (Care Compare)National Healthcare Safety Network (NHSN): Clostridium difficileCMS Hospital Compare (Compare Care)

At this time, BlueHPN℠ is only offered to Administrative Services Only (ASO), Self-Funded commercial employer groups. It is not available for fully insured / individual U65 groups, State Health Plan (SHP), Medicare, Federal Employee Program® (FEP), or Medicaid patients.

Blue Distinction Centers

The Blue Distinction Center designation focuses solely on facilities' procedures and the outcomes, which are a result of the performance for all physicians who perform these procedures at the facility.

All facilities must reapply for the designation on a regular basis (typically every 18 - 36 months) to help maintain consistent quality among facilities that have earned the Blue Distinction designation. The purpose of this process is to confirm that Blue Distinction designated facilities continue to meet the selection criteria. Requirements for ongoing participation as a Blue Distinction Center may evolve as the programs matures, but generally includes evaluation of quality indicators in the areas of structure, processes and outcomes.

No. These programs focus on identifying (and recognizing) what it takes for health care facilities to deliver better outcomes for specific types of specialty care.

Selection criteria are unique for each Blue Distinction program, reflecting that particular area of specialized care. Understandably, a facility with proven expertise in one specialty area may or may not meet thresholds in other areas (for example, a Blue Distinction Center for Spine Surgery may not necessarily meet the selection criteria for becoming a Blue Distinction Center for Complex and Rare Cancers). A facility that has been designated a Blue Distinction Center in multiple areas of care has met our detailed criteria in each area.

Blue Distinction Centers for Bariatric Surgery are designated facilities within the participating Blue Cross and Blue Shield of North Carolina network that offer comprehensive bariatric surgery services for the purpose of weight loss.

Blue Distinction Centers for Cardiac Care designation are designated facilities within the Blue Cross and Blue Shield of North Carolina network that have demonstrated a commitment to quality care, resulting in better overall outcomes for cardiac care patients. These facilities demonstrate expertise in offering comprehensive cardiac services, including inpatient cardiac care and cardiac rehabilitation.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit Blue Cross and Blue Shield Association to learn more.

Blue Distinction Centers for Complex and Rare Cancers focus on multidisciplinary treatment planning and complex, major surgical treatments for the following malignancies:

  • Acute leukemia (inpatient/nonsurgical)
  • Bladder cancer
  • Bone cancer
  • Brain cancer - primary
  • Esophageal cancer
  • Gastric cancer
  • Head and neck cancers
  • Liver cancer
  • Ocular melanoma
  • Pancreatic cancer
  • Rectal cancer
  • Soft tissue sarcomas
  • Thyroid cancer - medullary or anaplastic

Blue Distinction Centers for Knee and Hip Replacement are designated facilities within the Blue Cross and Blue Shield of North Carolina network that demonstrate a commitment to quality care, resulting in better overall outcomes for knee and hip replacement patients. These facilities demonstrate expertise in offering comprehensive inpatient knee and hip replacement services, including total hip and knee replacement.

Blue Distinction Centers for Spine Surgery are designated facilities within the Blue Cross and Blue Shield of North Carolina network that demonstrate a commitment to quality care, resulting in better overall outcomes for spine surgery patients. These facilities demonstrate expertise in offering comprehensive inpatient spine surgery services, including discectomy, fusion and decompression procedures.

Blue Distinction Centers for Transplants are designated facilities within the Blue Cross and Blue Shield of North Carolina network that demonstrate a commitment to quality care, resulting in better overall outcomes for Transplant patients. These facilities demonstrate expertise in offering comprehensive inpatient Transplant services.

Some hospitals don't treat sufficient volumes for the specific specialty type, so they cannot be considered for the program. This program is also voluntary, so facilities that did not apply for consideration during the application cycle are not eligible to be designated as Blue Distinction Centers until they apply during a subsequent cycle.

That facility would no longer be part of the Blue Cross NC network or the Blue Cross Blue Shield Association network and would no longer be considered a Blue Distinction Center.

Blue Distinction is a designation awarded by Blue Cross NC and other Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality health care. The designation is based on rigorous, evidence-based selection criteria established in collaboration with expert physicians and medical organizations. The goals are to raise the quality of care delivered nationwide and to help consumers find specialty care at facilities proven to have delivered better overall outcomes.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more.

Blue Distinction Centers for Cardiac Care were developed in collaboration with the American College of Cardiology and Society of Thoracic Surgeons and with input from a national panel of expert physicians.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more.

Blue Distinction Centers for Spine Surgery are designated facilities within the Blue Cross and Blue Shield of North Carolina network that demonstrate a commitment to quality care, resulting in better overall outcomes for spine surgery patients. These facilities demonstrate expertise in offering comprehensive inpatient spine surgery services, including discectomy, fusion, and decompression procedures.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more.

Blue Distinction Centers for Cardiac Care were developed in collaboration with the American College of Cardiology and Society of Thoracic Surgeons and with input from a national panel of expert physicians.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association to learn more. 

Blue Distinction Centers for Bariatric Surgery were developed in collaboration with the American Society for Metabolic and Bariatric Surgery, Surgical Review Corporation, and American College of Surgeons and with input from a national panel of expert physicians.

Facilities are required to meet strict standards set by the medical community to earn the Blue Distinction name. Blue Cross and Blue Shield (BCBS) companies are committed to making this information easy to find and understand. Visit the Blue Cross and Blue Shield Association website to learn more.

You can find participating Blue Distinction Center facilities by following these instructions:

  • Visit our Find Care page and select "Look up a Doctor or Drug"
  • Log in to Blue Connect or browse as a guest
  • Select "Doctor or facility"
  • Search for a facility type
  • The search results will note which providers participate in Blue Distinction Center programs

Services received at facilities without a Blue Distinction Center designation may be covered under the terms of your benefits. Out-of-pocket costs may be higher if you receive care at a facility outside of the Blue Cross NC network. To find out which services and costs are covered under your policy for any facility, please call the Customer Service number on your Member ID card.

Rare cancers occur so infrequently that most general oncologists and surgeons see very few of these patients. Because the volume of these cases is so low, treatment and outcomes for these cancers can vary greatly by physician and by health care facility. It's important that health care consumers find facilities that have ample experience in treating their particular form of cancer. Looking ahead, Blue Cross and Blue Shield companies anticipate expanding the list of facilities designated as Blue Distinction Centers for Complex and Rare Cancers, as well as developing future designations for facilities that treat more common forms of cancer.

Flu shot program

Yes. Influenza viruses change every year. A new vaccine is used annually to fight the most current influenza virus. In addition, the antibody a person develops from the vaccine declines over time.

You are classified as high-risk if you fall under one of the following categories:

  • Anyone 65 years of age or older
  • People who are in contact with persons at increased risk of influenza-related complications
  • Residents or employees of a nursing home or other chronic care facility where some of the residents have chronic medical conditions
  • People who have a chronic medical condition, such as asthma or another lung disease, heart disease, diabetes, kidney disease, or blood disease
  • People who have immune system problems caused either by disease (e.g., HIV or lymphoma) or by medication (e.g., chemotherapy or radiation therapy)
  • Women who will be in the second or third trimester of pregnancy during flu season
  • Children or teenagers, 6 months–18 years of age, who are receiving long-term aspirin therapy
  • Health care workers who care for high-risk patients in the patients' homes

There are many ways you can protect yourself from contagious illnesses, including the flu:

  • Wash your hands frequently with soap and warm water.
  • Avoid touching your eyes, nose, and mouth.
  • Avoid close contact with people who are sick.
  • Cover your nose and mouth when you sneeze or cough.
  • If you do get sick, stay home from school or work.

The flu shot manufacturers, the Federal Drug Administration (FDA) and the CDC are committed to protecting people from the flu. All involved parties are working to meet the projected demand in the United States for the flu vaccine during the upcoming flu season.

Influenza usually occurs from November until April, with activity peaking between late December and early March. The optimal time for flu shots is during October through November; however, it is clinically beneficial to be vaccinated through December and January.

The Centers for Disease Control and Prevention (CDC) recommends that you receive a flu shot if you meet their criteria of high risk or fall under one of the following categories:

  • Anyone who wants to reduce the risk of contracting the flu
  • People over the age of 50
  • People with high blood pressure, irregular heartbeat, history of stroke or heart attack, a chronic disease, diabetes, compromised immune system, anemia, asthma or other breathing problems
  • A health care worker with high-risk patients
  • People who had required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic, kidney or blood cell diseases
  • People traveling to a foreign country
  • People living or working with persons who fit into one of these categories

Anyone who is allergic to eggs should avoid being vaccinated, since the virus used is grown in hens' eggs.

Influenza usually leaves its victims unable to function for several days and is responsible for more than 200,000 hospitalizations each year. Getting an annual flu shot is your best protection.