1 blue Cross Medicare AdvantageSM. A Section of the Blues Provider Reference Manual 2018. blue Cross Medicare Advantage and blue Cross Medicare Advantage Dual Care plans are HMO, HMO-POS, PPO, and HMO Special Needs Plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the blue Cross and blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico Medicaid program. Enrollment in HCSC's plans depends on contract renewal.
2 Table of Contents 1. Introduction Topic Page Our Name S5. This Manual S5. Our Plans S5. Hospital Services S6. Emergency Care S7. Laboratory Services S7. 2. General Information Topic Page Eligibility and Benefits S8. Verification of Coverage S8. ID Cards S9. ID Card Sample S9. Medical Records S11. Medical Records Review S11. Standards for Medical Records S12. 3. Claims Topic Page Claim Requirements S13. Submitting Claims S14. Coordination of Benefits S14. Claim Disputes S14. Recovering Overpayments S15. Balance Billing S15.
3 Reimbursement S15. S1. 4. Benefits and Member Rights Topic Page Nondiscrimination S16. Confidentiality S16. Plan Benefits S17. 24-Hour Coverage S18. Access and Availability S19. Provider Availability S19. Member Rights S20. Member Responsibilities S21. Member Satisfaction S22. Cultural Competency S22. Preventive Services S22. Out of Area Renal Dialysis S23. Drugs Covered under Medicare Part B S23. Medical Supplies with Delivery of Insulin S24. Advance Directives S24. Additional Benefits S24. 5. Selection and Retention of Providers Topic Page Participation Requirements S25.
4 Credentialing S25. Recertification S25. Appeals Process S26. Notifying Members of Provider Termination S26. Medicare Opt Out Providers S27. 6. Performance and Compliance Standards Topic Page Evaluating Performance S28. Compliance with Standards of Care S28. Laws Regarding Federal Funds S30. Marketing S30. Sanctions S30. Reporting Obligations S31. Annual Model of Care Training Requirements S31. DSNP Training Requirements S32. S2. 7. Utilization Management Topic Page Organization Determinations S34. Overview S34. Standard Time Frames S34.
5 Expedited Determinations S35. Adverse Determinations S35. Medical Necessity S36. Medical Policy S37. Overview S37. National Coverage Determinations (NCDs) S37. Local Coverage Determinations (LCDs) S37. Medicare Coverage Database S38. Preauthorization Requirements S39. Services Requiring Preauthorization S39. Skilled Nursing Coverage S42. Termination of Services S42. 8. Case Management Topic Page Care Coordination S43. Initial Health Risk Assessment S43. Annual Health Assessment S43. 9. Appeals and Grievances Topic Page Overview S44.
6 Resolving Grievances S45. Resolving Appeals S45. Further Appeal Rights S45. Detailed Notice of Discharge S46. SNF, HHA, and CORF Discharge Notification Requirements S47. Detailed Explanation of Non-coverage (DENC) S48. S3. 10. Quality Improvement Topic Page Overview S49. Chronic Care Improvement Program (CCIP) S49. Quality Improvement Project (QIP) S49. Healthcare Effective Data and Information Set (HEDIS) S49. Consumer Assessment of Healthcare Providers and Systems S49. (CAHPS). Health Outcomes Survey (HOS) S50. Quality of Care Issues S50.
7 CMS Star Ratings S51. Contact Lists Glossary of Terms Attachments S4. 2018. 1 - Introduction Overview Our Name 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, is a Medicare Advantage Organization contracted with the Centers for Medicare and Medicaid Services (CMS) under contracts H3822, H3251, and H8634. This Section This Medicare Section of the Provider Reference Manual applies to professional and facility providers who and which are contracted as Network Providers for blue Cross Medicare Advantage .
8 The Blues Provider Reference Manual plus this Medicare Section explains the policies and procedures of the blue Cross Medicare Advantage network. Its terms are contractual and we hope it provides you and your office staff with helpful information as you serve blue Cross Medicare Advantage members. The information is intended to cover most situations your office will encounter while participating with BCBSNM for blue Cross Medicare Advantage . This Medicare Section of the Blues Provider Reference Manual is applicable only to the operation of blue Cross Medicare Advantage .
9 Our Plans blue Cross and blue Shield of New Mexico offers a range of Medicare Advantage plans including: HMO H3822 006: blue Cross Medicare Advantage Dual Care (HMO D SNP) special needs plan for beneficiaries who receive both Medicare and Medicaid. Premiums, copayments, coinsurance, and deductibles may vary based on the level of extra help a member receives HMO H3822-002: blue Cross Medicare Advantage Basic HMO. plan for Medicare beneficiaries who are not eligible for our Dual Care Special Needs plan HMO H3822-003: blue Cross Medicare Advantage Premier HMO plan for Medicare beneficiaries who are not eligible for our Dual Care Special Needs plan Continued on next page 1.
10 S5. 2018. Overview, Continued Our Plans (continued) PPO H8634-002: blue Cross Medicare Advantage PPO plan for Medicare beneficiaries who are not eligible for our Dual Care Special Needs plan H3251: HMO HMO-POS Medicare Advantage plan for Medicare beneficiaries who are not eligible for BCBSNM Medicare Advantage Dual Care Special Needs plan blue Cross and blue Shield of New Mexico maintains and monitors Network Providers including physicians, hospitals, skilled nursing facilities, ancillary providers and other health care providers through which members obtain covered services.