Blue Cross Community Centennial Plan

1 Such services are funded in part with the State of New Mexico. blue Cross and blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the blue Cross and blue Shield Association Section of the provider Reference PRM Section Cover 14/19/18 1:13 PMBlue Cross Community Centennial Plan Page S2 December 2018 blue Cross and blue Shield of New Mexico provider Reference manual blue Cross Community Centennial Section Table of Contents Topic Page Introduction S3 Program Overview S4 Claims S32

2 Reimbursement Methodologies S39 Health Care Management S47 provider Performance Standards and Compliance Obligations S62 Selection and Retention of Participating Providers S72 Medical Records S76 Initial Decisions, Appeals, and Grievances S77 Member Rights and Responsibilities S80 Obligation to Provide Access to Care S84 Pharmacy Services S88 Glossary of Terms S94 Contacts List

3 S97 New Mexico Optional Advance Health Care Directive Form Attachment 1 provider Disclosure Form Attachment 2 blue Cross Community Centennial Plan Introduction Page S3 December 2018 Introduction HCSC Insurance Services Company (HISC), a wholly-owned subsidiary of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, has contracted with the State of New Mexico, Human Services Department, Medical Assistance Division (HSD/MAD), to offer a Centennial Care plan named blue Cross Community Centennial . blue Cross and blue Shield of New Mexico (BCBSNM), a Division of HCSC, has contracted with HISC to administer this program.

4 This section applies to physicians, professional providers (including laboratory and ancillary providers), agency-based Community benefit, self-directed Community benefit, and facility providers who have agreed to participate as blue Cross Community Centennial providers and who have signed agreements in place to include single case agreements. This addendum, along with the Blues provider Reference manual , explains the policies and procedures of the BCBSNM network. It provides you and your office staff with important information as you serve blue Cross Community Centennial members, and is incorporated by reference into your New Mexico Medicaid Managed Care Amendment or Agreement, as applicable, with BCBSNM.

5 The information is likely to apply in most situations your office will encounter while participating in these programs. This section of the Blues provider Reference manual is applicable only to the operation of the blue Cross Community Centennial plan. blue Cross Community Centennial Network blue Cross Community Centennial is a Medicaid Managed Care Plan that focuses on breaking down the financial, cultural, and linguistic barriers preventing low-income families and individuals from accessing health care. BCBSNM maintains and monitors a network of participating professional, facility and ancillary providers (including physicians, hospitals, behavioral health providers, long-term care providers, skilled nursing facilities, and other health care providers) through which members obtain covered services.

6 blue Cross Community Centennial Plan Program Overview Page S4 December 2018 Program Overview blue Cross Community Centennial Plan Overview Centennial Care is the modernization of the New Mexico Medicaid managed care program as developed by New Mexico (HSD) under an 1115 waiver application to Centers for Medicaid & Medicare Services (CMS). Under blue Cross Community Centennial , BCBSNM will provide a seamless program for Medicaid-eligible individuals to meet their health care needs across the full array of Medicaid services, including acute and long-term care, behavioral health care, and home and Community based services (HCBS). A fundamental focus of the blue Cross Community Centennial plan will be to identify members at highest risk of poor health outcomes, using a person-centered approach, developing personalized plans, and providing appropriate access to covered services.

7 This integrated care approach focuses on health literacy, utilization of Community supports and resources to assist members in navigating the health care system, comprehensive care coordination, patient-centered medical homes, and the continuous development of health homes. This infrastructure will help to provide members access to the care they may need in a timely manner while enabling increased quality and better health outcomes. For new members to the BCBSNM Medicaid program or for existing members who may have encountered a health change status, BCBSNM makes reasonable efforts to contact these members to offer a Health Risk Assessment (HRA) or a Comprehensive Needs Assessment (CNA). The HRA screens for physical health, behavioral health, and long-term health care needs and can determine if a member requires a face-to-face CNA.

8 The CNA further informs BCBSNM of the needs and service gaps of the member and allows BCBSNM to assist the member to address these needs. These assessments will determine if the member will be assigned to a BCBSNM Care Coordination level two (2) or level three (3). A Care Coordinator will use the information collected during the CNA process to develop a care plan. The Care Coordinator will seek input from providers during the needs assessment process in order to develop a care plan that is comprehensive. Collaboration between blue Cross Community Centennial contracted providers and BCBSNM Care Coordination staff is necessary and is an expected condition of provider participation with BCBSNM.

9 Ongoing Care Coordination will be offered to members to facilitate the appropriate delivery of health care services and to offer access to the appropriate services, connection to the appropriate providers, as needed, identification of service gaps, and timely resolution to any identified service-related needs. Care Coordination activities will be provided at the level needed by the individual member but at least minimally as follows: Initial Health Risk Assessment, health education and referrals as requested, quarterly review of claims, and utilization data to screen for potential higher-level needs. Level 2: Member assigned a specific Care Coordinator, annual comprehensive needs assessment, semi-annual face-to-face visits and quarterly telephone contact with blue Cross Community Centennial Plan Program Overview Page S5 December 2018 member, care plan development and monitoring, health and disease management education, and potential assignment to a health home.

10 Level 3: Member assigned a specific Care Coordinator, semi- annual comprehensive needs assessment, quarterly face-to-face visits and monthly telephonic contact with member, care plan development and monitoring, health and disease management education, and potential assignment to a health home. Whether directly providing Care Coordination or some other health care service, providers throughout the system of care will be better prepared to provide quality care by understanding and participating in Care Coordination activities. The level of participation may vary depending on individual member needs but might include sharing or receiving information from an assigned Care Coordinator, being aware of the member s overall care plan, participating in integrated care planning, and the like.