Important Plan Reminders for BlueCHiP for Medicare

Professional / Behavioral Health / Facilities

We wanted to remind you about the following important information:

Referral Policy
Referrals are not required for a BlueCHiP for Medicare member to see an in-network specialist.

BlueCHiP for Medicare Members' Right to Know Their Treatment Options and Participate in Decisions About Their Healthcare.
Members have the right to get full information from their providers when they go for medical care. Members have the right to participate fully in decisions about their healthcare. As a provider, you must explain things in a way that members can understand and inform members of all of their treatment options that are recommended for their condition, no matter what they cost or whether they are covered by BlueCHiP for Medicare. This includes letting members know that there are Medication Therapy Management Programs offered by BlueCHiP for Medicare. Members have the right to be told about any risks involved in their care. Members must be told in advance if any proposed medical care or treatment is part of a research experiment, and be given the choice of refusing experimental treatments. Members have the right to receive a detailed explanation from BCBSRI if they believe that they have been denied care they believe they were entitled to receive, or care they believe they should continue to receive. In these cases, members must request an initial decision called an organization determination or a coverage determination. Members also have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if their doctor advises them not to leave. This also includes the right to stop taking their medication. If members refuse treatment, they accept responsibility for what happens as a result of their refusing treatment.

For more information on Medication Therapy Management Programs offered by BlueCHiP for Medicare, please direct your patients to call the BlueCHiP for Medicare concierge number on the back of their member ID card. If you would like more information, please call the Physician and Provider Call Center at (401) 274-4848 or 1-800-230-9050.

Standards of Care
As a provider in the BlueCHiP for Medicare network, you shall provide to members covered health services in accordance with the same professionally recognized standards of care as offered to your other patients, in accordance with BCBSRI's standards for comprehensive, high-quality patient care, and appropriate utilization of inpatient, ambulatory, ancillary, and emergency services, and in accordance with all applicable laws, rules, and regulations of professional ethics.

As a provider in the BlueCHiP for Medicare network, you shall not deny, limit, or condition the furnishing of healthcare services or otherwise discriminate in the treatment of members or in the quality of services provided to Members on the basis of race, sex, age, religion, disability, national origin, place of residence, health status (including but not limited to, medical condition; claims experience; receipt of healthcare; medical history; genetic information; or evidence of insurability, including acts arising out of domestic violence), or source of payment and shall observe, protect, and promote the rights of members as patients. This information is referenced in the Administrative Policies, Sections 3.3-1 and 3.3-2 of your contract with BCBSRI.

Peak Health Solutions

Professional / Behavioral Health / Facilities

We have partnered with Peak Health Solutions to collect medical records on our behalf. This effort is to ensure that the medical costs for our Medicare Advantage population is aligned with the federal dollars received to cover those costs. Peak Health Solutions may contact you by direct mail, fax, and phone. We understand the administrative effort required to provide the medical record information and thank you in advance for your cooperation.

If you have any questions pertaining to requests made by Peak Health Solutions, please contact them directly at 1-888-446-8150, Monday through Friday, 8:00 a.m. to 6:00 p.m.

Claims & Benefits

Reminder: Provider Financial Responsibility for Pre-Service Review

Professional / Behavioral Health / Facilities

As a reminder, participating BlueCard providers are financially responsible for inpatient facility services that need pre-service review, which includes notification, precertification, preauthorization, and prior approval. Previously, the member was financially responsible for those services. This change was effective July 1, 2014.

The Host (BCBSRI) and Home (the out-of-state Blues plan) plan providers must hold members harmless when a pre-service review is not received for inpatient facility services, unless responsibility for a pre-service review is otherwise specified in the member and/or group account contract.

Participating BlueCard providers may also be required to obtain a pre-service review for outpatient facility and professional services. Blues plans may have different rules on whether the provider or member is financially responsible if a pre-service review is not received for outpatient services.


Updated Guidance for the Use of Palivizumab (Synagis) Prophylaxis


The American Academy of Pediatrics published updated guidelines for infants and young children at increased risk for hospitalization from respiratory syncytial virus. Our prior authorization criteria have been revised based on these updated recommendations. Providers should contact our Pharmacy Benefit Manager, Catamaran, to request prior authorization for our members who have pharmacy coverage for this therapy. For our members who do not have pharmacy coverage, Synagis is covered under the medical benefit and providers should contact the Physician & Provider Service Center at (401) 274-4848 or 1-800-230-9050 (out of state only), Monday through Friday, 8:00 a.m. to 4:30 p.m., to request prior authorization.


Artificial Pancreas Device System

Professional / Facilities

A new policy has been written to document the coverage guidelines for Artificial Pancreas Device Systems as a result of new HCPCS codes published effective July 1, 2014. Artificial Pancreas Device Systems are considered not medically necessary because there is insufficient medical literature to support the efficacy of this treatment. Please see full text of this policy