2017 Neighborhood HMO Benefit Plans for Individuals/Families

Introduction

The BCBSAZ Neighborhood Network has been available in 2017 for individuals and families purchasing PCP Coordinated Care HMO Plans on or off the Exchange. These unique plans are designed to offer a supportive experience that helps members get the most out of their healthcare plan and avoid surprise charges.

In 2018, the PCP Coordinated Care Plans will continue to be available to individuals and families, using only the Neighborhood Network. The individual/family plans will be offered to residents of all Arizona counties except Maricopa and Pima.

New for 2018: PCP Coordinated Care Plans will be available to employer groups, using the Statewide HMO Network, and also in Pima County, the PimaConnect Exclusive Network. See more information about the 2018 PCP Coordinated Care Plans.

Neighborhood Network HMO benefit plans are different from other BCBSAZ HMO benefit plans

There are important differences that make these plans (prefixes NNG and NNJ) unique:

  1. Designated PCP – members must have a designated Primary Care Provider (PCP) to support much of their overall healthcare experience.
  2. Expanded precertification requirements – there are additional requirements beyond those included in most standard BCBSAZ benefit plans.
  3. BCBSAZ-approved referrals are required for most in-network specialist office visits – to help support coordinated in-network care and avoid surprise charges. Members have no benefit coverage without required referrals from their PCP.
  4. Narrow network for pharmacy benefits (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 by BlueCard Traditional providers.

eLearning Modules

These eLearning modules can be downloaded to view at your convenience or to share with your staff.
2017 Neighborhood HMO Plans - 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 Neighborhood Network. Specialties include:

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

Members requesting their designated PCP to be an OB-GYN or Pediatrics sub-specialist provider will be approved on a case-by-case basis. The OB-GYN or Pediatrics sub-specialist will need to submit a PCP Consent Form to BCBSAZ in order to be approved.

PCP Selection – Using claims history, BCBSAZ connected renewing members with their most recently visited PCP. For new members, zip code information is used to make an initial PCP selection. In order to be selected, a PCP must have an office location outside of Maricopa County.

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 results page as soon as it becomes effective. 

Remember, members will have no benefit coverage for office visits to PCPs other than their current designated PCP (or a qualified covering 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 & Benefits Inquiry" tool.

On the member ID card:

ID card image

On the "Eligibility and Benefits Detailed Results" page:

Screenshot of Eligibility and Benefits Detailed Results page

Covering PCPs

Neighborhood Network Providers who have been selected as a designated PCP for a member with a Neighborhood HMO plan 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. Neighborhood Network 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 the "Neighborhood HMO."

Screenshot of Practice Management tool

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Expanded precertification requirements

What are the expanded precertification requirements for Neighborhood HMO benefit plans?

Neighborhood HMO benefit 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 Neighborhood 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 Neighborhood HMO members. 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 Neighborhood Network 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.

Please note: 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 Neighborhood HMO member

  • Online Precert Tool – the online precertification tool for Neighborhood HMO benefit plans is available 24/7 on the secure provider portal. This tool is designed to work only for members with Neighborhood HMO benefit 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 the online precert tool – two locations!

    1. In "Practice Management" under "Neighborhood HMO," click on the "Submit/View Referrals and Precertification" link and enter the required information.
    2. Screenshot of Practice Management page

    3. On the "Eligibility & Benefits Detailed Results" page for Neighborhood HMO members, click on the "Submit/View Referrals and Precertification" link and enter the required information.
    4. Screenshot of Practice Management page

  • Fax Form – a fax form is available on the secure provider portal for providers to request referrals and precertification for members with Neighborhood HMO benefit plans.

  • Phone – call for Neighborhood HMO medication precertifications: 
         Pharmacy Prior Authorization: 1 (866) 325-1794
         Specialty Medications Prior Authorization: 1 (844) 807-5106
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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, Neighborhood 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 Neighborhood Network:

  • 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 covering 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 Neighborhood Network 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 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 Neighborhood HMO member

  • Online Referral Tool – the online referral tool is vailable 24/7 on the secure provider portal at azblue.com/providers. This tool is designed to work only for members with Neighborhood HMO benefit plans and only the member's designated PCP (or covering PCP) can request a referral approval from BCBSAZ. 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 the online tool – two locations!

    1. "Practice Management > Neighborhood HMO > Submit/View Referrals and Precertification."

      Screenshot sample of online tool

    2. On the “Eligibility and Benefits Detailed Results” page for Neighborhood HMO members, click on “Submit/View Referrals and Precertification.” 

      Screenshot sample of online tool

  • Fax Form a fax form is available on the secure provider portal for providers to request referral approvals and precertification for members with Neighborhood HMO benefit plans. See above screen shots. Approval status is faxed back by the next business day.

  • Phonecall Neighborhood 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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How to identify a Neighborhood HMO benefit plan

What are the member ID prefixes for Neighborhood HMO benefit plans?

There are only two prefixes for Neighborhood HMO benefit plans: NNG and NNJ

What information is shown on the online Eligibility & Benefits Inquiry results page?

The "Eligibility and Benefits Detailed Results" page clearly indicates that the member has a Neighborhood HMO benefit plan and will also display the designated PCP for that member. In addition, there will be links to the online referral/precert tool and the current precertification requirements list.

Screenshot of Eligibility and Benefits detailed results table image

Member ID cards for Neighborhood HMO benefit plans

The member ID card displays one of two prefixes (NNG or NNJ) and clearly indicates Neighborhood HMO. Designated PCPs for each family member are shown on the front of the card.

Sample ID card for Neighborhood HMO member


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Neighborhood Network providers

Which facilities, and professional and pharmacy providers are contracted for participation in the Neighborhood Network?

In Coconino and Maricopa counties, only certain providers are in network. In other counties, the Neighborhood Network includes most contracted providers. See the table below for more specific information.

The Pharmacy network includes all contracted retail pharmacies except CVS/Target.

Coverage outside of Arizona – for urgent care outside of Arizona, Neighborhood HMO members must use providers in the BlueCard Traditional Network (see BCBS National Directory). Neighborhood 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.

Providers participating in the Neighborhood Network

Neighborhood Network table image

* These facilities are considered part of the contracted entity and are not listed separately in the provider directory.  http://azblue.com/neighborhood

Member education

Helping members understand the differences in the 2017 Neighborhood HMO benefit plans

Members with Neighborhood Network benefit plans are being educated about the value of supported care, how it works, and the importance of selecting in-network providers to avoid surprise charges. Reference the member-specific brochure to see the explanations and instructions.