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BlueCare - HMO

Copay, Deductible and Coinsurance Based Plans

 

Listed below are the UM requirements in accordance with the terms of your Health Options provider agreement. If a service is not listed below, there was not a contractual obligation identified; however, this page is designed to provide general guidelines for this line of business. Benefits vary according to the terms of the member contract. Check Availity for your member's specific guidelines.  

Notification to Health Options of a member referral is not required when the PCP refers a member to a participating specialist or the participating specialist refers a member to another participating specialist.

Please access Medical Policies (Medical Coverage Guidelines) for supporting information regarding the criteria used in determining coverage for payment purposes. All services must meet the definition of medical necessity as outlined in the Member's benefit contract. Although a service may not require authorization, it is still required to meet the definition of medical necessity and is subject to medical necessity review pre-service, post-service or concurrently.

Note: If the HMO member's primary coverage is Medicare, then authorization is not required for participating physicians and providers, except for behavioral health services and self-administered pharmacy services. However, authorizations are required for all referrals to non-participating physicians and providers for all HMO member, regardless of primary coverage.

Service Contractual Obligation
Advanced Imaging
(CT Scans, MRIs/MRAs, PET Scans, Nuclear Medicine)
Authorizations are required and should be requested from NIA for CT scans, MRAs, MRIs and cardiovascular office and outpatient procedures. Refer to the NIA section for additional information.
Ambulance
Authorization required for non-emergency transport only.  
Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.
Behavioral Health Services
Inpatient: All inpatient psychiatric and substance abuse admissions require authorization and must be coordinated through New Directions Behavorial Health. Inpatient authorizations are coordinated with New Directions by the admitting facility.  
Outpatient: Behavioral health services are managed under an exclusive arrangement with New Directions. No authorization is required for the initial 8 outpatient visits per provider, per calendar year.
Partial hospitalization, IOP and substance abuse rehabilitation:
Require authorizations and must be coordinated through New Directions.
Birthing Centers Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Chemotherapy/Radiation Therapy Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

PADP applies

Clinical Education
(e.g. Diabetes)
Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Dialysis Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Durable Medical Equipment (DME) and Medical Supplies (MS)
For all providers not contracted through CareCentrix.  Authorization required for all DME and medical supply (MS) requests. Requests should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delay this process, the provider should advise our UM department.

For all providers contracted through CareCentrix.  DME or MS items should be accessed through CareCentrix. CareCentrix will arrange for services to be rendered by one of its participating providers or, when appropriate, will arrange for an out-of-network provider to provide the service should an in-network choice be unavailable (On this rare occasion, the member's claim will be processed with the in-network benefit).

Authorization requests to CareCentrix from referring physicians/providers can be submitted by phone at 877-561-9910 or by fax at 877-627-6688. Authorization requests from CareCentrix participating providers can be submitted by phone at 877-561-9910, by fax at 877-627-6688, or online through the CareCentrix web portal at https://www.carecentrixportal.com.
You should also refer to Florida Blue's Medical Policies (Medical Coverage Guidelines) for specific requests. DME or medical supplies that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization.
Home Health/Home Infusion

For all providers not contracted through CareCentrix.  Authorization required for all home health requests.  Requests should be submitted five working days prior to the date needed or within 24 business hours of the physician's order.  Payment will be denied  if authorization is not obtained.  If extenuating circumstances exist that delay this process, the provider should advise our  UM department.

Home health/home infusion are managed under an exclusive arrangement with CareCentrix for Health Options, and must be accessed through CareCentrix.

CareCentrix will arrange for services to be rendered by one of its participating providers or, will arrange for an out-of-network provider to provide the service should an in-network choice be unavailable (On this rare occasion, the member's claim will be processed with the in-network benefit).

Authorization requests to CareCentrix from referring physicians/providers can be submitted by phone at 877-561-9910 or by fax at 877-627-6688. Authorization requests from CareCentrix participating providers can be submitted by phone at 877-561-9910, by fax at 877-627-6688, or online through the CareCentrix web portal at https://www.carecentrixportal.com
Hospice Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Hospice services require submission of the request and a treatment plan (hospice plan) by the member’s PCP or participating provider for review and approval by Health Options.

If the services on the claim are not the same as those authorized, the claim will be held for review.

Hyperbaric Oxygen Hyperbaric oxygen treatment (99183, A4575, C1300) requires authorization.

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Infertility Treatment Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Injectable Medication Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Inpatient
(Acute, Psych, Substance and LTAC)
Authorization required

 

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Note: Newborn admissions require separate authorization from mother if either baby stays after mother is discharged, admission will be billed with DRG 789-793, or if mother is not insured through Florida Blue.

Laboratory Must use Quest Diagnostics and/or Ameripath.  If unable to use Quest Diagnostics, then a prior authorization is required.

 

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

To view a list of laboratory services permitted in the physician’s office, access the In-Office Laboratory Services list.
Office and Outpatient Diagnostic Test Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Exception: Participating physicians have standing authorizations for approval of certain diagnostic tests. Click here to view a list of codes.

Ophthalmology Ophthalmology for South Florida (Broward, Martin, Miami-Dade, Okeechobee, Palm Beach and St. Lucie counties) – members and/or physicians should coordinate services with EMI.
Oral Maxillofacial Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

 

Orthotics and Prosthetics (O&P)
Authorization is required for all O&P requests. Requests should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delay this process, the provider should advise our UM department.
O&P items should be accessed through CareCentrix. CareCentrix will arrange for services to be rendered by one of its participating providers or when appropriate, refer the member to the applicable Health Options O&P provider that can render the needed services.

Authorization requests to CareCentrix from referring physicians/providers can be submitted by phone at 877-561-9910 or by fax at 877-627-6688. Authorization requests from CareCentrix participating providers can be submitted by phone at 877-561-9910, by fax at 877-627-6688, or online through the CareCentrix web portal at https://www.carecentrixportal.com.

Standing Authorizations For BlueSelect, some O&P items do not require a prior authorization and are considered to have a standing authorization for approval based on medical appropriateness of a Health Options member’s condition.
Refer to the BlueSelect DME/MS/O&P page for a list of those items. Any items not included in this standing order section are subject to a prior authorization. 
 
You should also refer to Florida Blue’s Medical Policies (Medical Coverage Guidelines) for specific requests. DME or medical supplies that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization.
Outpatient Hospital Services
(including 23 hour Observation Care)
Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

All outpatient psychiatric and substance abuse admissions must be coordinated through New Directions Behavorial Health.

Note: Labor check billed under revenue codes 720, 721 and 729 do not require authorization.

Outpatient Rehabilitation Authorization required

Submit authorization requests electronically through Availity or contact BCBSF using Blue Express, our automated phone system.

Pain Management Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Pharmacy
(Provider Administered)
Benefits vary by member contract and may contain medical cost share. This information can be found in Availity.
  • Refer to the Medication Guide to determine drugs that require prior authorization
  • PADP applies
  • Hemophilia program – managed by Caremark
  • Self-administered drugs may not be covered in the office except those used in the treatment of diabetes, cancer, conditions requiring immediate stabilization (e.g. anaphylaxis), or in the administration of dialysis which are covered. Refer to the Medication Guide for a listing of drugs classified as self-administered.
  • Refer to the Pharmacy section for additional pharmacy program details.
Pharmacy
(Self-Administered)
Benefits vary by member contract. This information can be found in Availity.
  • Refer to the Medication Guide to determine drugs that require prior authorization.
  • Hemophilia program – managed by Caremark
  • Refer to the Medication Guide for drugs covered under this plan.
  • Some self-administered drugs require prior authorization as identified in the Medication Guide.
  • Refer to the Pharmacy section for additional pharmacy program details.
Skilled Nursing Facility (SNF) Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

The voluntary Select Medication Program is available to participating SNFs with access to select high-cost medication through Ambient Healthcare and Coram Infusion Specialty for members admitted for sub-acute care. See the SNF program for specific details.

Surgical Procedures
Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Potentially cosmetic, plastic, or reconstructive surgery is subject to medical necessity review.

Therapy
Physical/Occupational/Speech Language Pathologists
Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

Transplant Services
(excluding office visit)
Authorization required

Submit authorization requests electronically through Availity or contact Florida Blue using Blue Express, our automated phone system.

 

Health Options Financial Incentives Policy for UM Programs

The policy on financial incentives for UM programs applies to practitioners, providers, and employees involved in, or those who supervise those involved in making coverage and benefit UM decisions. Our policy on financial incentives is as follows:

  • UM decision making is based on the factors set forth in our definition of medical necessity for coverage and payment purposes in accordance with Health Options' medical policy guidelines, then in effect, and the existence of coverage and benefits under a particular contract, policy or certificate of coverage. Health Options is solely responsible for determining whether expenses incurred, or to be incurred, or whether medical care is, or would be, covered or paid under a contract policy. In fulfilling this responsibility, Health Options shall not be deemed to participate in or override the medical decisions of any Health Options member's physician or provider.
  • Health Options' payment policies are not designed to reward practitioners or other individuals conducting UM for issuing denials of coverage or benefits.
  • Financial incentives for UM decision makers are not designed to encourage decisions that result in under utilization. Rather, the intent is to minimize coverage and payment for unnecessary or inappropriate health care services, reduce waste in the application of medical resources, and minimize inefficiencies, which may lead to the artificial inflation of health care costs.
6/24/2014
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

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