Blue Shield. CCHCA Physician Handbook

Transcription

1 Part II Section C Blue Shield Introduction 1 Verifying Blue Shield Member Eligibility and Benefits 1 Blue Shield Sample Member ID Card 2 Pharmacy Benefit 5 Member Grievance Forms 9 CCHCA Physician Handbook

2 Blue Shield Introduction CCHCA became a participating medical group under Blue Shield in August of Blue Shield of California, an independent member of the BlueCross BlueShield Association, is a not-for-profit health plan dedicated to providing Californians with access to high quality care at a reasonable price. Founded in 1939, it now has 3.3 million members, 4,800 employees, one of the largest provider networks and more than 20 office locations, providing a wide range of commercial and government products throughout the state. Authorizations, claims for professional services, and utilization for Blue Shield members who are enrolled under the CCHCA Medical Group/Chinese Hospital will continue to be handled in the same manner as the other CCHCA programs. Please refer to the CCHCA guidelines in this manual for further information or reference. CCHCA utilizes Primary Care Physicians (PCP) for the Blue Shield Program. The same utilization protocol is used as in our other CCHCA programs. Members who have chosen CCHCA as their medical group must use CCHCA plan physicians for services. Referral physicians must also be from within the medical group. Exceptions require prior authorization from the Utilization Management Department. All claims, and authorizations for Blue Shield members enrolled under the CCHCA medical group will be processed by the Health Plans Office. Refer to Part I, Section 7 for the mailing address for paper and electronic claims. (Do not submit claims to Blue Shield. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) As with other CCHCA programs, the Blue Shield program utilizes a co-payment system. The amount to be collected varies for each plan, and should be collected from the patient at the time of service. Some of the member ID cards will carry the amount of the office visit co-payment. Verifying Blue Shield Member Eligibility and Benefits If you have any questions concerning patient eligibility, benefits or co-payments, please call Blue Shield at Blue (2583). Eligibility can also be obtained at the Blue Shield website at CCHCA Physician Handbook, Part II, Section C 1

3 Blue Shield HMO ID Card Sample Note: ID cards are subject to change and are intended to depict general look and feel only. CCHCA Physician Handbook, Part II, Section C 2

4 Blue Shield Access+HMO ID Card Sample Note: ID cards are subject to change and are intended to depict general look and feel only. CCHCA Physician Handbook, Part II, Section C 3

5 Interpreting the ID Cards: Subscriber Name: The subscriber s name covered by the plan listed here. Subscriber ID Number: A twelve digit number. HMO Copayments: Office: The office visit copayment to be collected at the time of service. Varies with benefit package. Hosp: The hospital copayment to be collected at time of admission. Emerg: Emergency room copayment to be collected at the time of service. Group Number: The HMO account number assigned to the subscriber s employer group. Effective Date: Subscriber s eligibility effective date in a Blue Shield HMO plan or the effective date of a status change. RX: Yes indicates the plan has prescription benefits. Language: The subscriber s language preference, if other than English. IPA/medical group Name: The IPA/medical group with which the Personal Physician is affiliated. A+ Status: An A+ indicates that the member participates in Access+ HMO and the IPA/medical group is an Access+ Provider Group. Subscriber Name and Selected Personal Physician: The name of each covered family member is listed with their selected Personal Physician, the effective date with the Personal Physician, the Personal Physician s 24-hour telephone number and the Personal Physician s IPA/medical group affiliation. CCHCA Physician Handbook, Part II, Section C 4

6 Blue shield Prescription Drug Program Pharmacy Benefits The pharmacy benefit for Blue shield members is administered by Blue shield. Providers should call Blue Shield Pharmacy services at for further information regarding the pharmacy coverage. Prior Authorizations for Medications Certain drugs may require prior-authorization before the drug is covered. Authorization for medications requiring prior authorization can be obtained by calling Blue Shield Pharmacy Services at (800) (A sample copy of the prior authorization medication request form can be found on the ensuing pages). High-Cost Specialty Drugs For Office Use Attached is a list of very high-cost specialty drugs specified by Blue Shield that must be obtained from CuraScripts. These medications will be shipped to your office by CuraScript at NO CHARGE to you. Payment for these specialty drugs will be made by Blue Shield directly to CuraScript. Steps To Follow: 1. Fill out the CuraScript Patient Enrollment Form. 2. Tape a signed written prescription for the medication to the right side of the form as indicated. 3. Fax this form and prescription to (888) When the processing and authorizations are complete, CuraScript will call your office and the patient to coordinate the shipment of the medication(s). Note: NO authorization numbers are required for submission. This absence of an authorization number is non-standard for CuraScript so representatives might still request one. The CuraScript representative should be informed that the authorization number is NOT required if they ask. CCHCA Physician Handbook, Part II, Section C 5

7 Should You Need Help: CuraScript Help Line: CuraScript Help (888) am to 6pm ET CCHCA Physician Handbook, Part II, Section C 6

8 Sample Prescription Medication Request Form CCHCA Physician Handbook, Part II, Section C 7

9 Sample High Cost Injectables Enrollment Form CCHCA Physician Handbook, Part II, Section C 8

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