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New Options for Affordable Health Insurance

MA PAP219

New Providers Joining Contracting Groups


Provider Administrative Policy

Section
Provider Information
Policy Date
November 2007
Status/Date
Revised/September 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

New Providers Joining Contracting Groups

Provider Status
Providers joining contracting groups are not contracting for True Blue® HMO or Secure BlueSM PPO until they have passed credentialing and have been notified of their effective date with True Blue HMO, Secure Blue PPO and/or Flexi BlueSM PFFS.

  • Submission of a credentialing application does not satisfy this requirement.

New Providers Joining Existing Groups – True Blue HMO
When a new provider joins an existing group, they are not covered by the group contract until they have passed credentialing. Blue Cross of Idaho will notify you of the provider effective date with True Blue.

  • For services rendered prior to the provider’s effective date, you must obtain approved authorization from the Medicare Advantage care coordination team.
  • Failure to schedule a member with a contracting provider or obtain a prior authorization will result in non-payment of the claim.
  • Prior authorization approval must be obtained before services are rendered.
  • Request for prior authorization must include medical necessity justification or the member will be redirected to a contracting provider. Scheduling convenience for the provider or member does not constitute medical necessity.

New Providers Joining Existing Groups – Secure Blue PPO
When a new provider joins an existing group, they are not covered by the group contract until they have passed credentialing. We will notify you of the provider effective date with Secure Blue.

  • For services rendered prior to the provider`s effective date, services will be considered
    out-of-network and paid at the member’s out-of-network cost sharing.

Policy History

Date Action Reason
September 2012 Revised Removed reference to Flexi Blue

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