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. Representatives must complete an attestation form at the end of training.
If you have an issue with completing the attestation form online after reviewing the Model of Care training, you can print a copy of the form, complete all required information and fax to 919-765-7109. You can also submit via email to DSNP_providerattestations@bcbsnc.com.
Submit claims with Availity®
All claims for Healthy Blue + Medicare members must be filed through Availity. You can learn more about using Availity by visiting the Training and Education page.
Do not submit Healthy Blue + Medicare HMO D-SNP claims through Blue e provider portal.
Forms
These forms are specific to Healthy Blue + Medicare HMO D-SNP and are required when doing business with Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Please complete forms related to pre-certification, behavioral health treatment, and other similar cases before rendering service.
- 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℠ (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. - April is National Minority Health Month and Stress Awareness Month (PDF)
- A Way to Help Lower-Income Patients Pay for Internet Service (PDF)
- Accuracy in Documentation: Documenting Cancer- History vs Current Condition
- Adult Immunization Status (AIS-E) (PDF)
- Availity: Medicare provider-facing talking points and FAQ (PDF)
- Availity Portal Overview (PDF)
- Be Antibiotics Aware: Protect Your Patients (PDF)
- Blue Cross and Blue Shield of North Carolina Expands Specialty Pharmacy Precertification List (PDF)
- Blue Cross and Blue Shield of North Carolina Expands Specialty Pharmacy Precertification List (February 2024) 1 (PDF)
- Blue Cross and Blue Shield of North Carolina Expands Specialty Pharmacy Precertification List (February 2024) 2 (PDF)
- Blue Cross NC and Anthem Collaboration
- Breast Cancer Screening (BCS-E) (PDF)
- Care Part B Expansion Adstiladrin, Altuviiio, Idacio, Lamzede, Lunsumio, Rebyota, Signifor LAR, Syfovre, Vivimusta (PDF)
- Carelon Medical Benefits Management, Inc. Updates (PDF)
- Carelon Medical Benefits Management, Inc Updates November 2023 (PDF)
- Carelon Medical Benefits Management, Inc. Updates February 2024 (PDF)
- Carelon Medical Benefits Management, Inc. Updates March 2024 (PDF)
- CarelonRx, Inc. Mail Changed to CarelonRx Pharmacy on January 1, 2024 (PDF)
- Change Healthcare Cyber Security Update (PDF)
- Clinical Criteria Updates November 2022 Healthy Blue + Medicare (HMO D-SNP) (PDF)
- Clinical Criteria Updates - March 2023 (PDF)
- Clinical Criteria Updates - May 2023 (PDF)
- Clinical Criteria Updates November 2023 Healthy Blue + Medicare℠ (HMO D-SNP) (PDF)
- Clinical Criteria Updates - December 2023 (PDF)
- Clinical Criteria Updates - February 2024 (PDF)
- Clinical Criteria Updates - March 2024 (PDF)
- Clinical Laboratory Improvement Amendments (PDF)
- Colorectal Cancer Screening Toolkit Fact Sheet (PDF)
- Conducting the Medicare Annual Wellness Visit Via Telehealth: Guide for Office, Nursing and Provider Staff (PDF)
- Depression Screening and Follow-up for Adolescents and Adults (DSF-E) (PDF)
- Electronic Data Interchange Overview (PDF)
- Expanded Specialty Pharmacy Precertification List (PDF)
- Expansion of Specialty Pharmacy Precertification List (January 2024) (PDF)
- Expansion of Specialty Pharmacy Precertification List (February 2024) (PDF)
- Expansion of Specialty Pharmacy Precertification List (March 2024) (PDF)
- How to Navigate Patient360 through the Availity Portal (PDF)
- Healthy Blue + Medicare D-SNP Supplemental Guide (PDF)
- Heart Healthy Diets: A Collaborative Approach Between Provider and Patient (PDF)
- HEDIS 2023 Documentation for Blood Pressure Control for Patients with Diabetes (BPD) (PDF)
- HEDIS 2023 Electronic Clinical Data Systems (ECDS) (PDF)
- HEDIS 2024 Documentation for Care of Older Adults (COA) (PDF)
- HEDIS 2024 Documentation for Colorectal Cancer Screening (COL-E) (PDF)
- HEDIS 2024 Documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC) (PDF)
- HEDIS Measurement Year 2023 Documentation for Childhood Immunization Status (CIS) (PDF)
- HEDIS Measurement Year 2023 Documentation for Transitions of Care (TRC) (PDF)
- Health Outcomes Survey (PDF)
- Health Outcomes Survey: Fall Risk Management (FRM) (PDF)
- Health Outcomes Survey: How to Improve the Patient Experience (PDF)
- Health Outcomes Survey: Management of Urinary Incontinence in Older Adults (MUI) (PDF)
- Health Outcomes Survey: Physical Activity in Older Adults (PAO) (PDF)
- Hispanic Heart Health Month (PDF)
- Importance of Timely Submission of Medicare Risk Adjustment Data (PDF)
- Improving the Patient Experience (PDF)
- Inappropriate Primary Diagnosis (PDF)
- Introducing an Enhanced Claims Status Feature for Availity Essentials (PDF)
- Itemized Bill Review Program (PDF)
- Long Term Acute Care (LTAC) Precertification Worksheet (PDF)
- Medical Drug Benefit Clinical Criteria Update (PDF)
- Medical Policies and Clinical UM Guidelines
- Medical Policies and Clinical Utilization Management Guidelines Update (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update for May 2023 (PDF)
- Medical Policies and
Clinical Utilization Management Guidelines Update for March 2024 (PDF) - Medical Step Therapy - Rituxan Agents (PDF)
- Medicare Advantage Skilled Nursing Facility/Rehabilitation Pre-Certification Worksheet (PDF)
- Medicare Annual Wellness Visit Workflow (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 27th Edition (PDF)
- Notification of Specialty Pharmacy Medical Step Therapy Updates (PDF)
- Osteoporosis Screening in Older Women (OSW) (PDF)
- Outpatient Antibiotics Provider Toolkit (PDF)
- Personalized Match Phase 1 (PDF)
- Personalized Match Phase 1: Specialist Provider Overview (PDF)
- Pharmacotherapy Management of COPD Exacerbation HEDIS Measure (PDF)
- 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). - Prior Authorization Requirement Changes Effective August 1, 2023 (PDF)
- Prior Authorization Requirement Changes Effective November 1, 2023 (PDF)
- Prior Authorization Requirement Changes Effective December 1, 2023 (PDF)
- Prior Authorization Requirement Changes Effective February 1, 2024 (PDF)
- Prior Authorization Requirement Changes Effective March 1, 2024 (PDF)
- Prior Authorization Requirement Changes Effective March 1, 2024 (2) (PDF)
- Prior Authorization Requirement Changes Effective May 1, 2024 (1) (PDF)
- Prior Authorization Requirement Changes Effective May 1, 2024 (2) (PDF)
- Prior Authorization Requirement Changes Effective May 1, 2024 (3) (PDF)
- Prior Authorization Requirement Changes Effective May 1, 2024 (4) (PDF)
- Prior Authorization Requirement Changes Effective May 1, 2024 (5) (PDF)
- Prior Authorization Requirement Changes Effective July 1, 2024 (PDF)
- Provider Manual (PDF)
- Providing a Superb Patient Experience (PDF)
- Providing Preventive Care in an Urgent Care Setting: Guide for Urgent are Clinical Team Members (PDF)
- Remittance Inquiry Reference Guide (PDF)
- Resources to Control High Blood Pressure (Hypertension) (PDF)
- Save Time with Claim Status Enhancements from Availity (PDF)
- Social Need Screening and Interventions (SNS-E)
- Somatus is your Resource for Kidney Care Management (PDF)
- Specialty Pharmacy Medical Step Therapy for Hyaluronan Injections (PDF)
- Statin Therapy End of Year Practices (PDF)
- Submitting Prior Authorizations Is Getting Easier (PDF)
- Unspecified Diagnosis Code of Site and Laterality (PDF)
- UPDATED: Blue Cross NC Expands Specialty Pharmacy Precertification List (PDF)
- Usage of Liability Modifiers (PDF)
- Using Pre-appointment Questionnaires to Decrease Annual Wellness Visit (AWV) Appointment Time (PDF)
Reimbursement policies
- Abortion (Termination of Pregnancy) (PDF)
- Claims Submission - Required Information for Facilities (PDF)
- Claims Submission – Required Information for Professional Providers (PDF)
- Claims Timely Filing (PDF)
- Code and Clinical Editing Guidelines (PDF)
- Corrected Claims (PDF)
- Diagnosis-Related Group (DRG) Inpatient Facility Transfers (PDF)
- Diagnosis Used in DRG Computation (PDF)
- Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (PDF)
- Durable Medical Equipment (DME) (Rent to Publish) (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)
- Global Surgical Package (PDF)
- Inpatient Readmissions (PDF)
- Maternity Services (PDF)
- Maximum Units Per Day (PDF)
- Modifier 22 (PDF)
- Modifier 24 (PDF)
- Modifiers 25 and 57 (PDF)
- Modifiers 26 and TC (PDF)
- Modifiers 50 and 51 (PDF)
- Modifier 63 (PDF)
- Modifier 66 (PDF)
- Modifier 76: Repeat Procedure by the Same Physician (PDF)
- Modifier 77 (PDF)
- Modifier 90 (PDF)
- Modifier 91 (PDF)
- Modifiers LT and RT (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)
- Proof of Timely Filing (PDF)
- Prosthetic and Orthotic Devices (PDF)
- Reduced and Discontinued Policies (PDF)
- Reimbursement for Items under Warranty (PDF)
- Reimbursement Policies Disclaimer (PDF)
- Reimbursement Policies Overview (PDF)
- Sanctioned and Opt-Out Providers (PDF)
- Split Care Surgical Modifiers (PDF)
- Sterilization (PDF)
- Technology Assisted Surgical Procedures (PDF)
Sample member ID cards
Contact information
Healthy Blue + Medicare customer service
Healthy Blue + Medicare customer service
PO Box 62947
Virginia Beach, VA 23466
Phone: 833-713-1078
Fax: 855-358-1226
Medicare complaints, appeals & grievances (medical and drugs Part C)
Attention: Medical Necessity Provider Appeals
Mailstop: OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040
Phone: 833-713-1078
Fax: 888-458-1406
For coverage decisions and appeals for Part D drugs
Prime Therapeutics
Medicare Appeals Department
10802 Farnam Dr.
Omaha, NE 68154
Phone: 800-725-7710
For difficulties with hearing or speaking, please call 800-693-6703.
Fax: 888-285-2242
Provider services (medical & drug)
Phone: 844-895-8160
Fax: 877-799-4129
Healthy Blue + Medicare
PO Box 60007
Los Angeles, CA 90060-0008
Case management (medical & drug)
Phone: 866-611-4287
Fax: 855-443-7821
Healthy Blue + Medicare
3350 Peachtree Road NE
Atlanta, GA 30326
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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