Image of a healthcare professional treating a child

2018 PCP Coordinated Care HMO Benefit Plans

Introduction

PCP Coordinated Care HMO plans are designed to offer a supportive experience that helps members get the most out of their healthcare plan and avoid surprise charges. This type of HMO plan will continue to be available to individuals/families, using the Neighborhood Exclusive Network.

New for 2018, these plans will be offered to employer groups, using the Statewide HMO Network (includes Maricopa County) and also for those in Pima County, the PimaConnect Exclusive Network.

Effective January 1, 2018, the BCBSAZ provider networks and member ID prefixes associated with PCP Coordinated Care HMO Plans (PCP-HMO) are:

PCP Coordinated Care HMO Plans Table

PCP Coordinated Care HMO benefit plans are different from Open-access HMO benefit plans

There are important differences that make these plans unique:

  1. Designated PCP – Members must have a designated Primary Care Provider (PCP) to support much of their overall healthcare experience.
  2. BCBSAZ-approved referrals are required for most in-network specialist office visits – This helps ensure in-network care and avoid surprise charges. Members have no benefit coverage without required referrals from their PCP.
  3. Expanded precertification requirements – There are additional requirements beyond those included in most standard BCBSAZ benefit plans.
  4. Narrow network for pharmacy benefits– The Pharmacy network excludes CVS / Target.
  5. No coverage for services from out-of-network providers inside or outside of Arizona except for emergent care or in cases where BCBSAZ has authorized out-of-network care because the services cannot be provided in network. Urgent care outside of Arizona is covered only when rendered by providers in the BlueCard© Traditional network.

eLearning Modules for provider staff training

These eLearning modules can be downloaded to view at your convenience or to share with your staff.

  • 2018 PCP Coordinated Care HMO Benefit Plans – What You Need to Know Download the PDF.
  • Online Tool for Referrals and Precertifications – Mini User Guide Download the PDF.

Designated PCPs

How are designated PCPs selected or changed?

The member’s designated PCP must be a medical professional (M.D., D.O., or N.P.), actively practicing as a PCP, and contracted with BCBSAZ to participate in the network associated with the member’s benefit plan. Specialties include:

  • Internal Medicine
  • Family Medicine
  • General Practice
  • Pediatrics (for members up to age 19)

Requests from members to select an OB-GYN or Pediatrics sub-specialist provider to be their designated PCP will be approved on a case-by-case basis. The OB-GYN or Pediatrics sub-specialist must submit a PCP Consent Form to BCBSAZ in order to be approved.

PCP Selection – For an initial PCP selection, BCBSAZ uses claims history to connect members transitioning to PCP Coordinated Care HMO Plans with their most recently visited PCP. For new members, zip code information is used to make an initial PCP selection.

PCP Changes – Members may request a different designated PCP up to six times a year. To check the status of a member’s PCP change, do an online eligibility & benefits inquiry – the updated PCP selection is displayed on the member's detailed results page as soon as it becomes effective. 

Remember, members have no benefit coverage for office visits to PCPs other than their current designated PCP (or a covering qualified PCP – see information below about Covering PCPs).


Where to find the member’s designated PCP information

The current PCP name and designation effective date are displayed on the member ID card. The designated PCP is also shown on the "Detailed Results" page of the online "Eligibility and Benefits Inquiry" tool.

The designated PCPs are displayed on the member ID card for each family member:

Image of Blue Cross Blue Shield ID card

The designated PCP is displayed on the member’s “Eligibility and Benefits Detailed Results” page:

 Screenshot of Eligibility and Benefits Detailed Results Page

Covering PCPs

Providers who have been selected as a designated PCP must have covering PCPs for times when they are not available. A covering PCP must be an MD, DO or NP, actively practicing as a PCP, and contracted for participation in the network associated with the member's benefit plan. PCPs and PAs within the designated PCP’s practice (same tax ID) will automatically be considered covering PCPs – no notification to BCBSAZ is necessary.

Designated PCPs who do not have covering PCPs within their practice (same tax ID) must notify BCBSAZ of covering PCPs (and any changes). Up to three covering PCPs can be kept on file at any one time. Use the Covering PCPs Form to notify BCBSAZ of other covering PCPs (different tax IDs).

Designated PCP Panel Rosters

Designated PCPs can download a list of currently attributed members. Click on the PCP Panel Roster link in "Practice Management" under "PCP Coordinated Care HMO

Screenshot of the PCP Panel Roster location

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BCBSAZ-approved Referrals for in-network specialist office visits (includes telemedicine)

About specialist referrals

To help support in-network, coordinated care, designated PCPs must submit referral requests to BCBSAZ for office visits to most in-network specialists. The following provider types do not need a referral as long as the provider is participating in the network associated with the member's benefit plan:

  • OFFICE-BASED SERVICES
    • OB-GYN professionals
    • Behavioral/Mental Health professionals
    • OP Therapy – PT/OT/ST (precert is required after meeting the allowed limit of 60 visits combined for Habilitative and Rehabilitative visits)
    • Chiropractors
    • Dental and vision services for eligible members (age 18 or younger, until the end of the policy year in which the member turns age 19)
  • NON OFFICE-BASED SERVICES
    • Urgent Care Centers
    • Retail Health Clinics (please note: CVS MinuteClinics are not in-network for Neighborhood HMO benefit plans)
    • Facilities (hospitals, radiology centers, labs, PT/OT/ST, SNFs, mental health facilities, etc.)

For all other specialist office visits, members will have no coverage (claim will be denied) and have to pay for office visits if they do not have a BCBSAZ-approved referral from their designated PCP (or a qualified PCP – see information above on Covering PCPs) on file with BCBSAZ. Members may view the status of a referral on the BCBSAZ secure member portal at azblue.com/member.

Referrals to providers who do not participate in the network associated with the member's benefit plan must be pre-certified. Failing to obtain precertification for out-of-network services will result in a claim denial, except for emergency services.

About the BCBSAZ process for referral approvals

The BCBSAZ referral approval process helps support coordinated, in-network care with three simple and proactive steps:

  1. The designated PCP (or covering PCP) submits a referral request to BCBSAZ.
  2. BCBSAZ validates that:
    a) The referral request was submitted by the designated PCP (or qualified covering PCP) in advance of the service.
    b) The referral is to an in-network specialist.
  3. If both of the above conditions are validated, BCBSAZ approves the request.

How long does a referral last?

For services that don’t require precertification, a BCBSAZ-approved specialist referral covers all office services rendered by that specialist (or another provider in the same tax ID and specialty, for the same type of specialty services) for up to one year.

For services that require precertification, the referral is specific to that particular service and the precert will not be approved unless the BCBSAZ-approved referral is in place. The timeline of the referral will correspond with the timeframe of the precertification.

Who is included for a specialist referral?

When a member is referred to a specialist, providers in the same tax ID and specialty are included for the referral, including other MDs, DOs, NPs, and PAs if they are contracted with BCBSAZ.

How to request or view a referral for a member with a PCP Coordinated Care HMO Plan

  • Online Tool for Referrals/Precert – available 24/7 on the secure provider portal, this tool works only for members with PCP Coordinated Care HMO Plans. You cannot use it for members with any other type of benefit plan. When using the online tool for referral requests, the approval process is automated with results displayed on the status page almost immediately.

    Sample of Online Tool "Status" page:

    Screenshot sample of online tool

  • Finding and using the online tool for referrals/precert – two locations!

    1. In the secure provider portal: “Practice Management” > “PCP Coordinated Care HMO,” > “Submit/View Referrals and Precertification."

    2. Screenshot of provider navigation showing location of, referrals and precertifications

    3. On the member's “Eligibility and Benefits Detailed Results” page, click on “Submit/View Referrals and Precertification."

    4. Screenshot of Eligibility and Benefits detailed results page
  • Fax form – for referral requests. Download the Fax Form – also available in the secure provider portal.
    (Approval status is faxed back by the next business day.)

  • Phone – for referral requests or status, call:

    PCP Coordinated Care HMO Provider Service: 1 (844) 807-5106. (Approval status is available by the next business day if it can’t be issued during the call.)

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Expanded precertification requirements

About the expanded precertification requirements

PCP Coordinated Care HMO Plans have additional precertification requirements beyond those typically found in most other BCBSAZ PPO and HMO plans. View the complete list of precertification requirements for PCP Coordinated Care HMO Plans. For example, the following services require precertification (not an all-inclusive list):

  • Inpatient (for emergency admissions, notify within 2 business days of admission)
  • Certain outpatient surgery procedures
  • High tech radiology (MRI, PET, CT, etc.)
  • Certain outpatient infusion medications
  • Epidural/facet injections/radiofrequency ablation
  • Certain Durable Medical Equipment (DME)
  • Genetic testing
  • Sleep studies

Precertification may be requested for elective admission or services to be scheduled within 30 days (precert date ranges may vary).

Provider Penalties

Like most BCBSAZ benefit plans, a $500 penalty will be applied to network providers for failure to obtain precertification for all services requiring precertification for members with PCP Coordinated Care HMO Plans. For facility-related precertification requirements (such as inpatient admissions, SNF, EAR, LTAC), the penalty applies to the facility and not the professional provider. The provider may not bill the member for this penalty amount. Provider processes and procedures for precertification are covered in the Provider Operating Guide, Section 12.

Precertification for Out-of-network Services

Referrals to providers not contracted for participation in the network associated with the member's benefit plan must go through a precertification process. Failing to obtain precertification for out-of-network services will result in a claim denial, except for emergency services.

For Neighborhood Network in Maricopa County – the only health systems in the Neighborhood Network are Banner Health and Dignity Health, to provide services not available in other counties.

How to request or view a precertification for a member with a PCP Coordinated Care HMO Plan

  • Online Tool for Referrals/Precert – available 24/7 on the secure provider portal, this tool works only for members with PCP Coordinated Care HMO Plans. You cannot use it for members with any other type of benefit plan. If you need to attach documentation for precertification, use the fax form to submit your request instead of the online tool.

  • Finding and using the online tool for referrals/precert – two locations!

    1. In the secure provider portal: “Practice Management” > PCP Coordinated Care HMO > Submit/View Referrals and Precertification.

    2. Screenshot of Panel Roster page

    3. On the member's “Eligibility and Benefits Detailed Results” page, click on “Submit/View Referrals and Precertification." 

    4. Screenshot of Eligibility Benefits Inquiry page image

    • Fax form – Download the Fax Form – also available in the secure provider portal.

    • Phone – for medication precertification requests or status, call:
                 
           Pharmacy Prior Authorization: 1 (866) 325-1794
           Specialty Medications Prior Authorization: 1 (844) 807-5106
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How to identify PCP Coordinated HMO Benefit Plan

What are the member ID prefixes for PCP Coordinated Care HMO Plans?

The following prefixes indicate a PCP Coordinated Care HMO Plan:

Image of PCP Coordinated Care HMO Plan

Information displayed on the online Eligibility and Benefits Detailed Results page

The “Eligibility and Benefits Detailed Results” page clearly indicates that the member has a PCP Coordinated Care HMO Plan and also displays the designated PCP for that member. In addition, there are links to the online tool for referrals/precert and the current precertification requirements list.

Screenshot of Eligibility and Benefits detailed results page

Member ID cards for PCP Coordinated Care HMO Plans

The member ID card displays one of the above listed prefixes and clearly indicates the designated PCPs for each family member on the front of the card.

Sample ID card for members with PCP Coordinated Care HMO Plans

Blue Cross Blue Shield ID card image

Blue Cross Blue Shield ID card image

Blue Cross Blue Shield ID card image

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In-network providers for members with PCP Coordinated Care HMO Plans

Coverage outside of Arizona

For urgent care outside of Arizona, members with HMO Plans must use providers in the BlueCard® Traditional Network (see BCBS National Directory). HMO members have no other access to out-of-network providers inside or outside of Arizona except for emergent care or when BCBSAZ has authorized use of an out-of-network provider because the service is not available from a network provider. See below for specific information about in-network coverage within Arizona.

Coverage inside of Arizona

For 2018, there are three networks associated with PCP Coordinated Care HMO Plans. Two of these networks are available only to employer groups (Statewide HMO Network and PimaConnect Network). The Neighborhood Network is only available to individuals/families. Members must use providers within the network associated with their benefit plan. See below for specific information about these networks.

  1. Statewide HMO Network – with narrower Pharmacy network

    The Statewide HMO Network includes most BCBSAZ contracted providers. This network is available to employer groups for both Open-access and PCP Coordinated Care HMO Plans. For PCP Coordinated Care HMO Plans, the Pharmacy network includes all contracted retail pharmacies except CVS/Target.

    View directory listings at https://azblue.com/StatewideHMO.

  2. PimaConnect Exclusive Network – with narrower Pharmacy network

    PimaConnect includes facilities and provider groups associated with Tucson Medical Center. This network is available to employer groups for both PPO and PCP Coordinated Care HMO Plans. For PCP Coordinated Care HMO Plans, the Pharmacy network includes all contracted retail pharmacies except CVS/Target. See the table below for more specific information.

    Pima Connect Providers table image

    *These entities are considered part of the contracted facility and are not listed separately in the provider directory.

  3. View directory listings at https://azblue.com/PimaConnect.

  4. Neighborhood Exclusive Network

    Neighborhood Network is available only to individuals/families for PCP Coordinated Care Plans. In Coconino and Maricopa counties, only certain providers are in network. In other counties, the Neighborhood Network includes most contracted providers. The Pharmacy network includes all contracted retail pharmacies except CVS/Target. See the table below for more specific information.

    Neighborhood Providers Table Image

    *These entities are considered part of the contracted facility and are not listed separately in the provider directory.

    View directory listings at http://azblue.com/neighborhood

Member education

Helping members understand their PCP Coordinated Care HMO Plans

BCBSAZ educates members with PCP Coordinated Care HMO Plans to help them understand the value of supported care and how it works. They are guided to avoid surprise charges by adhering to referral requirements and selecting providers within the network associated with their benefit plan. Reference the member-specific brochure to see the explanations and instructions.