Healthy Living Product Participation Requirements
Provider Administrative Policy
DisclaimerOur 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.
To establish requirements for participation in the Healthy Living product for clinics.
Efficiency: A measurement of each clinic in relation to their clinic peer group that reflects both treatment cost and utilization resulting in an efficiency score to determine eligibility for participation in the Healthy Living product.
Clinic: An individual physician or group of physicians and practitioners collectively who is/are licensed to practice medicine in the state of Idaho and is/are jointly engaged in the provision of care through employment, partnerships or other sufficient arrangements. The term clinic as used within this document shall refer to both the singular clinic as an organization and the multiple individual clinic physicians.
Clinic Peer Group: Blue Cross of Idaho contracting clinics practicing within the same field of medical specialty.
Corrective Action Plan: A written, detailed plan submitted to Blue Cross of Idaho by clinic physician or clinic that adequately demonstrates the clinic physician or clinic will take necessary steps to meet the Healthy Living product participation requirements. The plan shall address the areas of noncompliance identified by Blue Cross of Idaho and include a time line in which compliance with the participation requirements will be achieved. Blue Cross of Idaho will notify the clinic physician or clinic of its approval of the plan. Written notification of completion of the corrective action plan must be transmitted by the clinic physician or clinic to Blue Cross of Idaho. Failure to timely notify Blue Cross of Idaho of completion of the corrective action plan may result in termination of participation from the Healthy Living product.
Health Qualification Form: A form required by Blue Cross of Idaho for a Healthy Living member to be eligible for the enhanced benefit of the Healthy Living product. The form is required to be completed and submitted annually within 90 days of enrollment by the member.
Physician Review Panel: Two or more Blue Cross of Idaho`s medical directors to review a clinic`s or clinic physician`s efficiency score.
1. Clinics must meet the following requirements to participate in the Healthy Living product:
a. Clinics must be commercial point of service contracting and in good standing.
b. Clinics must comply with all other commercial point of service policies and procedures.
c. Clinic physicians must be credentialed by Blue Cross of Idaho.
d. Clinic physicians must be board certified in their specialty.
e. Clinics must meet the Healthy Living product efficiency standard.
f. Clinics and clinic physicians must cooperate with Blue Cross of Idaho and member in coordinating members` health care. For primary care providers this will include completion of members’ health qualification forms.
2. Exceptions to participation requirements:
a. Certain identified clinic peer groups will not be evaluated for efficiency at this time. Clinics in these clinic peer groups must meet the other applicable requirements in this policy including credentialing by Blue Cross of Idaho unless they meet comparable credentialing requirements of the hospital(s) where they are privileged.
b. Clinic physicians who do not meet the Healthy Living product efficiency requirement or board certification requirement may participate in the Healthy Living product if the clinic in which they practice is eligible to participate and the clinic physician otherwise meets the requirements of this policy for participation. The participating clinic shall work with the clinic physician and Blue Cross of Idaho to develop an appropriate plan to address the unmet requirements.
c. If a clinic or clinic physician is not credentialed when the Healthy Living Product is first issued to members, he or she must return a completed credentialing application within 90 days of notification of the lack of credentialing. After the completed application is received by Blue Cross of Idaho, there shall be an additional 90 days to complete the credentialing review process.
d. If a clinic or clinic physician does not meet the Healthy Living product efficiency requirement but otherwise meets the requirements of this policy for participation, it/he/she may request its/his/her efficiency score be reviewed by the physician review panel.
3. Termination for noncompliance from Healthy Living product participation:
a. If a clinic physician and/or clinic do not continue to meet all of the participation requirements of this policy, Blue Cross of Idaho will notify the clinic physician and/or clinic of the specific areas of noncompliance.
b. The clinic physician and/or clinic may submit a corrective action plan to address areas of noncompliance.
c. A clinic physician and/or clinic may be terminated from participation in the Healthy Living product for failure to continue to meet the participation requirement(s) in this policy or to successfully complete the corrective action plan.
d. Blue Cross of Idaho will provide notification of termination from the Healthy Living product will be provided 90 days in advance of the termination effective date.
e. If clinic is terminated from participation in the Healthy Living product, the clinic may appeal such termination in accordance with the appeal provisions of the commercial point of service contract.
f. Termination of the clinic’s participation in the Healthy Living product is not termination of clinic`s commercial point of service contract.
4. Any clinic under Blue Cross of Idaho`s commercial point of service contract may apply for participation in the Healthy Living product. Upon receipt of clinic’s application for participation, Blue Cross of Idaho`s physician review panel will review clinic`s efficiency scores and other requirements for participation and upon request, review its decision with the applicant clinic.