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Provider Administrative Policy

Section
Information
Policy Date
February 2008
Status/Date
Revised/April 2012

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Company Profile for Medicare Advantage Plans

Blue Cross of Idaho's current Medicare Advantage plans include a health maintenance organization (HMO) plan and a preferred provider organization (PPO) plan. We will notify providers when additional types of plans become available under the Blue Cross of Idaho brand. The member's primary care physician coordinates care and some services require prior authorization.

True Blue HMO, a Medicare Advantage HMO, requires members receive care from providers participating in the Blue Cross of Idaho Medicare Advantage network. Those who are fully dual eligible for both Medicare and Medicaid may enroll and receive their Medicare and Medicaid services through the True Blue HMO Special Needs Plan. These members generally pay no copayments for services.

Secure Blue PPO, a Medicare Advantage PPO, allows members to utilize providers outside the Blue Cross of Idaho Medicare Advantage network. Members usually receive the highest level of benefit when choosing in-network providers but have the freedom to choose their providers.

Medicare Advantage plans cover all Medicare benefits, eliminating the need for a Medicare supplement plan. Medicare Advantage plans receive a premium from members and an average annual per capita cost from the Centers for Medicare and Medicaid Services (CMS) to cover healthcare and administration costs.

PROVIDER MANUAL PURPOSE
Blue Cross of Idaho's provider manual serves as a guide for working with our Medicare Advantage plans. The manual provides current operational guidelines and answers general questions about the plans. Policy changes occur on a quarterly basis and we issue notice if there is a negative impact to the provider prior to a change. The provider manual consists of Blue Cross of Idaho's Medicare Advantage Provider Administrative Policies, located on our Web site at www.bcidaho.com.

ACCOUNTABILITY
Under our Medicare Advantage contract, Blue Cross of Idaho is responsible for performing all CMS obligations and meeting all CMS regulations.


Policy History

Date Action Reason
April 2012 Revised Language clarification
January 2012 Revised Removed references to Flexi Blue
April 2010 Revised Language clarification
March 2009 Revised Removed language for primary eye physician
May 2008 Revised Language clarification

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