Healthy Blue Provider Manual

1 MedicaidBNC-PM-0002-21 Healthy Blue Provider ManualProvider Services: 844-594-5072 1 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) retains the right to add to, delete from and otherwise modify this Provider Manual . Contracted providers must acknowledge this Provider Manual and any other written materials provided by Blue Cross NC or Amerigroup Partnership Plan, LLC as proprietary and confidential. Material in this Provider Manual is subject to change. Visit for the most up-to-date information. Providers can obtain an online copy of the Provider Manual and view the Provider directory at To request a hard copy of the Provider Manual and/or Provider directory from the plan at no cost, call Healthy Blue Provider Services at 844-594-5072.

2 To view PDF documents, you will need Adobe Acrobat Reader. If you do not have it already, you can access the website for Adobe directly at Copyright October 2021 by Amerigroup Partnership Plan, LLC All rights reserved. This publication or any part thereof may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without the prior written permission of Amerigroup Partnership Plan, LLC. The Healthy Blue website is Healthy Blue Provider Manual 2 Welcome to the Healthy Blue network! We re pleased you have joined us. We combine national expertise with an experienced local staff to operate community-based health care plans.

3 We are here to help you provide quality health care to our members. Along with hospitals, pharmacies and other providers, you play the most important role in managing care. Earning your respect and gaining your loyalty are essential to a successful collaboration in the delivery of health care. We want to hear from you. We invite you to participate in one of our quality improvement committees. Or feel free to call Healthy Blue Provider Services at 844-594-5072 with any suggestions, comments or questions. Together, we can make a real difference in the lives of our members your patients. How to apply for participation If you are interested in participating in the Healthy Blue network and are registered with NC Medicaid via NC Tracks, visit or call 844-594-5072.

4 If you are not registered with NC Medicaid, visit to get started. How to apply for participation If you are interested in participating in the Healthy Blue network, visit or call 1-844-594-5072. How to apply for participation If you are interested in participating in the Healthy Blue network, visit or call 1-844-594-5072. How to apply for participation If you are interested in participating in the Healthy Blue network, visit or call 1-844-594-5072. Healthy Blue Provider Manual 3 Introduction 7 Who Is Healthy Blue? .. 7 Whom Do We Serve? .. 7 Quick Reference 7 Provider Claims Payment .. 2 Provider Information 4 Advanced Medical Homes (AMH) .. 5 Primary Care Providers .. 9 Responsibilities of the PCP.

5 10 Who Can Be a PCP? .. 13 PCP Onsite Availability .. 13 PCP Adequacy, Access and 17 Members Eligibility Listing and Panel 19 Specialty Care Providers .. 19 Role and Responsibilities of Specialty Care Providers .. 19 Role and Responsibilities of LTSS 20 Specialty Care Providers Access and Availability .. 20 Telehealth .. 22 Tribal 24 Member 25 PCP Auto Assignment Process for 27 Member ID 27 Member Missed 28 Noncompliant 29 Members With Special Health Care Needs .. 29 Covering Physicians .. 30 Provider Support .. 31 Reporting Changes in Address and/or Practice Status .. 32 Second 32 Medically Necessary Services .. 33 Provider Bill of Rights .. 34 Prohibited Marketing Activities.

6 34 35 Pharmacy Services .. 47 Value-Added Services .. 49 Services Covered Under the North Carolina State Plan or Fee-for-Service Medicaid .. 65 Well-Child Visits Reminder Program .. 66 Immunizations .. 67 Healthy Blue Provider Manual 4 Blood Lead Screening .. 68 Member Rights and Responsibilities .. 68 Member Grievance .. 70 Medical Necessity Appeals .. 71 Expedited Appeal .. 72 Continuation of Benefits During Appeals or State Fair Hearings .. 73 State Fair Hearing Process .. 74 Provider Appeals, Grievances and Payment Disputes .. 74 First Line of Defense Against Fraud .. 79 HIPAA .. 82 Steerage of Membership .. 83 Behavioral Health Services 83 83 Target Audience .. 84 84 Objectives.

7 85 Guiding Principles of the Behavioral Health 85 Systems of 87 Coordination of Behavioral Health and Physical Health Treatment .. 88 Behavioral Health Provider Roles and 89 Clinical 90 Member Records and Treatment Planning: Comprehensive 91 Member Records and Treatment Planning: Personalized Support and Care 92 Member Records and Treatment Planning: Progress 93 Psychotropic Medications .. 93 Behavioral Health Utilization Management .. 94 Access to Care 94 Behavioral Health Covered Services .. 95 Behavioral Health In Lieu of Services (ILOS).. 97 Medical Necessity Determination and Peer Review .. 97 Provider Medical Necessity Appeals .. 98 Provider Appeals, Grievances and Payment Disputes.

8 98 Avoiding an Administrative Adverse Decision .. 102 Clinical Practice Guidelines .. 103 Medical Policy .. 103 Emergency Behavioral Health Services .. 103 Behavioral Health 104 Requesting Behavioral Health Services .. 104 Links to Forms, Guidelines and Screening Tools .. 105 Member Management Support 105 Welcome Call .. 105 Healthy Blue Provider Manual 5 24/7 NurseLine .. 105 Care Management .. 106 Continuity of Care .. 108 New Baby, New Life Pregnancy Support Program .. 109 Disease Management/Population Health .. 111 Provider Directories .. 113 Cultural Competency .. 113 Member 116 Patient Visit 117 Advance Directives .. 118 Precertification/Prior Notification Process 118 Precertification of All Inpatient Elective Admissions.

9 120 Emergent Admission Notification Requirements .. 121 Nonemergent Outpatient and Ancillary Services Precertification and Notification Requirements .. 121 Prenatal Ultrasound Coverage Guidelines .. 122 Prior authorization/Notification Coverage Guidelines .. 123 Hospital Admission Reviews .. 131 Discharge Planning .. 132 Confidentiality of Information .. 134 Misrouted Protected Health Information .. 134 Emergency Services .. 134 Urgent Care/After-Hours Care .. 135 Quality Management 135 Quality Management Program .. 135 Quality of Care .. 135 Quality Management 136 Use of Performance Data .. 136 Medical Review Criteria .. 136 Clinical Criteria .. 137 Medical Advisory Committee .. 138 Utilization Management Decision 138 Utilization Management Committee.

10 138 Credentialing and Recredentialing .. 139 Provider Enrollment and Disenrollment .. 140 Peer Review .. 142 Claim Submission and Adjudication Procedures 143 Healthy Blue Provider Manual 6 Claims Submission .. 143 Electronic Data Interchange (EDI) Electronic Submission of 143 Paper Claims Submission .. 145 International Classification of Diseases, 10th Revision (ICD-10).. 148 Encounter Claim 149 Claims Adjudication .. 149 Clean Claims Payment .. 150 Claims Status .. 151 Reimbursement Policies .. 151 Coordination of Benefits and Third-Party Liability .. 152 Billing 154 Client Acknowledgment Statement .. 155 O verpayment Process .. 156 NCDHHS Encounter Data Submissions .. 157 Healthy Blue Provider Manual 7 INTRODUCTION Who Is Healthy Blue?