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PAP 635

ConnectedCare - Network Responsibilities


Provider Administrative Policy

Section
Commercial Managed Care
Policy Date
June 2012
Status/Date
New/ October 2013
Provider Type(s)
All Providers  

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

ConnectedCare - Network Responsibilities

Blue Cross of Idaho has partnered with health systems throughout Idaho to offer ConnectedCareSM, a suite of individual, family and group health insurance products that are modeled after accountable care organization (ACO) plans. The regional networks that support these products consist of a wide variety of primary care and specialty healthcare providers who are committed to providing high quality, cost-effective medical care to ConnectedCare members.

To receive the highest level of benefits, ConnectedCare members must select a primary care physician (PCP) from the appropriate network within their service area. PCPs will coordinate treatment, provide care when it is appropriate and refer members to specialists within the network when specialty services are needed.

Saint Alphonsus Health Alliance (SAHA)

ConnectedCare is supported in the Treasure Valley by the Saint Alphonsus Health Alliance (SAHA) network, serving ConnectedCare members in six counties within southwestern Idaho and eastern Oregon (Ada, Canyon, Gem, Payette, Washington counties in Idaho and Malheur County in Oregon).The SAHA provider resource center will coordinate member referrals from PCPs to specialists. You can contact the resource center at 208-367-DOCS (3627). We will process services provided by specialists without an approved referral or authorization at out-of-network benefit levels regardless of network affiliation. This includes any services provided by contracting providers with Blue Cross of Idaho ConnectedCare, Traditional, PPO or Managed Care networks.

Portneuf Quality Alliance (PQA)

ConnectedCare is supported in southeastern Idaho by the Portneuf Quality Alliance (PQA) network, serving ConnectedCare members in Bannock and Bingham counties. A member's PCP will coordinate referrals to specialists. We will process services provided by specialists without an approved referral or authorization at out-of-network benefit levels regardless of network affiliation. This includes any services provided by contracting providers with Blue Cross of Idaho ConnectedCare, Traditional, PPO and Managed Care networks.

You can identify members by the ConnectedCare logo on the front of their Blue Cross of Idaho ID card. Blue Cross of Idaho's provider administrative policy 102 (see PAP102) contains a picture of the ID card.

Providers contracted through the SAHA or PQA networks must:

  • Follow evidence based guidelines and quality standards
  • Coordinate member referrals for contracting and non-contracting specialists
  • Request prior authorizations for services outlined in provider administrative policy 241 (see PAP241)
  • When necessary, assist member in selection or assignment of PCP
  • Assist in resolution of access to care issues

See below for a list of ConnectedCare Referral Requirements:

Things that require a referral: Things that do not require a referral:
  • Visits or services by specialists/non-primary care providers; non-primary care specialties include, but are not limited to:
    • Allergy/Immunology
    • Behavioral Health
    • Cardiology
    • Cardiac/Cardiothoracic Surgery
    • Chiropractic
    • Colorectal Surgery
    • Dermatology
    • Endocrinology
    • ENT/Otolaryngology
    • Gastroenterology
    • General Surgery
    • Hand Surgery
    • Infectious Disease
    • Nephrology
    • Neurology
    • Neurosurgery
    • Oncology/Hematology
    • Ophthalmology/Optometry
    • Oral Surgery
    • Orthopedics
    • Pain Management
    • Plastic Surgery
    • Podiatry
    • Pulmonology
    • Rheumatology
    • Urology
    • Vascular Surgery
  • Any service provided outside the network
    Note:  OON referrals only approved when a service gap in the network exists
  • Visits or services by primary care providers or generalists; primary care specialties include the following:
    • Family Practice
    • General Practice
    • Internal Medicine
    • OB/GYN
    • Pediatrics
  • Anesthesia
  • DME Suppliers
  • Emergency or Urgent Care Services
  • Facility Services
  • Independent Lab Tests
  • Pathology
  • PT/OT/ST
  • Radiology/Imaging Services (Mammograms, X-rays, Ultrasounds, MRIs, CT scans, PET scans)
    *Note - professional or interventional radiology services may be subject to referrals as specialists
  • Registered Dieticians

 

 

 

 

 

 

 

 


Policy History

Date Action Reason
November 2013 Revised Added Registered Dieticians to "Things that do Not require a referral"
October 2013 Revised Updated to include PQA Network

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