Saturday 17 September 2016

Participating Provider Agreements


Your responsibilities and agreements as a participating provider are defined in your provider agreement(s). You should always refer to your agreement when you have a question about your network participation. As a participating provider, you also have the following responsibilities to our members— your patients:

• Submitting claims for Blue Cross and Blue Shield members.

This includes claims for inpatient, outpatient and office services. To ensure prompt and accurate payment, it is important that you provide all patient information on the CMS-1500 claim form (or the UB-04 claim form for certain allied providers) including appropriate Physicians’ Current Procedural Terminology (CPT®) codes and ICD-10-CM diagnosis codes. National Provider Identifiers (NPIs) are required on all claims (Blue Cross-assigned provider numbers are no longer used). The Claims Submission section of this manual gives specific information about completing the claim form as well as CPT and ICD-10-CM coding information. The Allied Health Providers section gives specific
information about completing the CMS-1500 and UB-04 claim forms.

• Accepting Blue Cross’ payment plus the member’s deductible, coinsurance and/or copayment, if applicable, as payment in full for covered services.

Blue Cross’ payment for covered services is based on your charge not to exceed Blue Cross’ allowable charge. You may bill the member for any deductible, coinsurance, copayment and/or noncovered service. However, you agree not to collect from the member any amount over Blue Cross’ allowable charge.

The Provider Payment Register/Remittance Advice summarizes each claim and itemizes patient liability, the amount above the allowable charge and other payment information. Additional information concerning the Payment Register/Remittance Advice is included in the Reimbursement section of this manual.

• Cooperating in Blue Cross’ cost-containment programs where specified in the Member Contract/ Certificate and not billing the member or Plan for any services determined to be not Medically Necessary or Investigational, unless the provider has notified the member in advance in writing that certain not Medically Necessary or Investigational services will be the member’s responsibility.
Generic or all-encompassing notifications to member will not meet the specific notification requirement mentioned here.

Certain Plan Member Contracts/Certificates include cost-containment programs such as prior authorization, concurrent review and case management. The member’s identification card will contain telephone numbers for prior authorization. Also, the member should inform you if his/her benefit program includes cost-containment provisions or incentives.

• Informing Blue Cross of your possible involvement in a concierge or membership program. Such involvement must be communicated in writing to your Network Representative before our members are contacted about this new process. Blue Cross will discuss with you your intentions and plans for the concierge or membership program and how it will impact our members.
 

Amendments to Provider Agreements


Blue Cross has the right to amend provider agreements by making a good faith effort to notify the provider at least sixty days prior to the effective date of the change.


NETWORK PARTICIPATION

Participating providers are those physicians and allied health providers who have entered into a provider agreement with Blue Cross and Blue Shield of Louisiana (herein referred to as Blue Cross or Plan). As a participating provider in our networks, you join other providers linked together through a business relationship with Blue Cross.

Our networks emphasize the primary roles of the participating provider and Blue Cross and Blue Shield.

They are designed to create a more effective business relationship among providers, consumers and Blue Cross and Blue Shield. Our participating provider networks:

• Facilitate providers and Blue Cross working together to voluntarily respond to public concern over costs
• Continue to give Blue Cross and Blue Shield members freedom to choose their own providers
• Demonstrate providers’ support of realistic cost-containment initiatives
• Limit out-of-pocket expenses for patients to predictable levels and reduce their anxiety over the cost of medical treatment
As applicable, providers are encouraged to comply with Interoperability Standards and to demonstrate meaningful use of health information technology in accordance with the HITECH Act.

As applicable, provider agrees to maintain a notice of HIPAA privacy practices, as required by HIPAA, at the point where a Plan Member would enter provider’s website or web portal.

No comments:

Post a Comment

Popular Posts