1. QCPI Orientation 2014 Quality Care Providers, Inc.
3350 Peachtree Road NE
Suite 1180
Atlanta, GA
Phone: (678)
Fax: (678)
Confidential Property of Quality Care Providers, Inc.

2. QCPI Welcome Orientation
Managed Care Products through QCPI’s Network
HMO Requirements
Primary Care Selection
Timeliness of Filing
LabCorp, National Reference Laboratory for BCBSGA
Precertification Requirements
Formulary
Practice Age Restrictions
Accessibility / Call Coverage
Credentialing
Reimbursement / Clinical Quality Integration Process
Incentive Programs
Network Manuals
Electronic Connectivity
BCBSGA Claims Issue Escalation Process
Resources
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3. BCBSGA Managed Care Products
Membership growth continues to be in the Blue Open Access HMO/POS Products
Commercial
State Health Benefit Plan
Exchange Products
PCPs are encouraged to use efficient technology resources
Availity: ICR and Patient Care Summary
MMH+
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4. Managed Care Products through QCPI
QCPI is the primary care network for the following BCBSGA products:
Gatekeeper Products:
BlueChoice Healthcare Plan, (HMO) product (a PCP designation is required)
BlueChoice Option, (POS) product (a PCP designation is required)
Open Access Products:
Blue Open Access HMO
Blue Open Access POS
Exchange Products through Pathway Networks
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5. Managed Care Products through QCPI
Identifying HMO/POS Products
Network Name
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6. SHBP Member ID card
Network in Georgia: this is the reimbursement you can expect
PPO “suitcase” for traveling benefits

7. HMO Requirements
Primary Care Physician Selection: For BlueChoice Healthcare Plan (HMO) and BlueChoice Option (POS) the PCP’s name is on the patient’s card. For Blue Open Access HMO/POS (including SHBP and Exchange plans), no PCP designation is required.
Timeliness of Filing: Claims filed (with or without preauthorization) after ninety (90) days from the date of the service will be denied for delay in timeliness of filing.
LabCorp: LabCorp is the exclusive national reference laboratory for all BCBSGA patients. All laboratory studies must be referred to LabCorp (or to an HMO contracted specialty or genetic laboratory provider) except those that have been approved as in-office laboratory procedure codes.
Precertification Requirements: View at
Formulary: View at
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8. HMO Requirements… cont’d
Practice Age Range Restrictions:
Internists 15 years and up
Family Practitioners ages 0-99
Pediatricians ages 0-20 (a Pediatrician is not to see an adult patient age 21 yrs or older)
Office Hours: 20 hours of patient contact per week, 4 days a week
Accessibility / Call Coverage: 24 hours, 7 days a week; covering PCP must be a QCPI In-Network PCP (who treats the same age group)
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9. Credentialing
Attained degree of Medical Doctor (MD) or Doctor of Osteopathy (DO)
Completed 3 years post-graduate training in internal medicine, family practice or pediatrics
Board certified within specialty or board certified within 5 years of completion of post-graduate training
* Recertification is required to maintain network participation
Valid, unrestricted medical license, active DEA number without limitations
Professional liability insurance coverage $1M/$3M
Use of CAQH online credentialing is required
120 days to complete the credentialing process for new physicians
Recredentialing is required every 3 years
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10. QCPI Reimbursement –Section 5 of the QCPI Manual
QCPI generally provides (30) days written notice of any reimbursement change; however only (10) days notice is required under QCPI Agreement
Gatekeeper Products:
PCPs are reimbursed either on a fee-for-service or capitation basis pursuant to QCPI’s Clinical Quality Integration Process
Open Access Products:
PCPs are reimbursed on a fee-for-service basis pursuant to QCPI’s Clinical Quality Integration Process
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11. Reimbursement / Clinical Quality Integration
Clinical Quality Integration - a process which aligns a physician group’s quality of care with its financial reimbursement for BCBSGA/BCBSHP’s managed care products.
Physician groups (including solo practitioners), after comparison to its peers, will be reviewed annually to receive a higher level of reimbursement, a lower level of reimbursement, or to remain on the same fee schedule.
Physician groups which generate an insufficient amount of data to allow for a meaningful analysis will NOT be affected.
The measures used to evaluate reimbursement are available on the QCPI website, and are communicated annually to network physicians.
The Physician Quality Report and notice of any fee schedule changes are mailed out annually.
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12. Quality and Incentive Programs
QCPI’s physician quality programs are designed to reward physicians who are able to effectively combine high quality preventive care with efficient use of resources.
Recognize & Reward Programs (R&R): Targeted preventive metrics to recognize quality. Those QCPI PCP’s who provide documented, measurable preventive care to their patients are given incentives (subject to the availability of funds) for meeting quality benchmarks. These programs require active participation through QCPI’s Rewards website.
Physician Quality Report: Our annual program provides each eligible PCP with a Physician Quality Report.
All of the measures for the above programs are available on the QCPI website.
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13. QCPI PCP Network Manual / Contract
Product Participation: Each PCP participates in the Gatekeeper Products and the Open Access Products.
Patients: Each PCP should accept new patients who seek to select the PCP as his/her PCP if the PCP is accepting new patients for any other health benefit plan which encourages patients to use a network of health care providers.
Panel Closing Policy: A PCP may close his/her patient panel to patients for the Gatekeeper Products and the Open Access Products according to Section 8.1 of the QCPI Network Manual.
Patient Move Policy ( See Section 8.3): If you change practices, but remain in the QCPI network (19 county service area) and your move is more than 10 miles to the new practice – your patients will be re-assigned to another QCPI provider. If you leave the QCPI network but remain a BlueCross physician, your patients will be re-assigned to another QCPI provider.
Amendments to Manual: 30 days notice
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14. QCPI PCP Network Manual / Contract –Changes & Notification
Section 11 of the QCPI Network Manual discusses the following:
Changing or adding location address
Changing Tax ID
Adding a new physician to practice
Departure of a physician from practice
Termination/Resignation by physician
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15. Coordination With BCBSGA: HMO Physician Office Manual
BCBSGA has published a network manual relating to the operations of the BCBSGA Products. The BCBSGA HMO Physician Office Manual addresses operational matters such as:
Contact information
Provider Services
Membership and Enrollment
The Primary Care Physician
Claims Filing
Electronic Connectivity (EDI Services)
Laboratory Tests (Lab Corp is required Lab)
Utilization Management
Preferred Drug List
Quality Management
Wellness Programs
NOTE: The BCBSGA HMO Physician Office Manual is incorporated by reference in your Independent Physician Agreement with QCPI (Agreement) and therefore a part of your entire contract
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16. Electronic Connectivity – BCBSGA
Secure multi-health plan portal with access to claims status, eligibility & benefits, claims status, AIM Specialty Health link, online remits. A a multi-payer portal that gives health care providers secure access with one sign-on to multiple payer’s information
Your practice’s use of Availity and Blue Cross and Blue Shield of Georgia’s ProviderAccess portals are currently included in the Technology Use Component of QCPI’s Clinical Quality Integration Process
QCPI also encourages its network physicians to:
File claims electronically with BlueCross
Use Electronic Funds Transfer/Electronic Remittance Advice
Use AIM Specialty Health® (AIM®) ProviderPortal - to pre-certify all advanced imaging studies (CT and MRI).
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17. Availity: www.availity.com
Self service tools like Interactive Care Reviewer (ICR) to request inpatient and outpatient precertifications for many members covered by BCBSGa plans:
Ability to find information on a precert previously submitted via phone, fax, ICR, or other online tool
Referral requests can also be submitted
Access this functionality under Auth and Referral (on the left of Availity website)
Secure Messaging for clarification on claims status
Patient Care Summary (formerly CareProfile):
Consolidated (HIPAA compliant) view of patient health care services for a health plan across providers at no cost
2 year summary of patient medical claims-based information
Ability to retrieve separate summaries if patient had coverage with more than one payer
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18. Member Medical History Plus – MMH+
Provides access to your BCBSGA patients medical and claims history online
Free, up to 5 years of information, HIPAA compliant
Medical history includes: past diagnoses, medications filled, lab results, procedures performed, other providers seen and care alerts
Access via internet URL
Contact Sherry Vallee to sign-up
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19. BCBSGA Claims Issue / Escalation Process
Claims Payment Inquiry: Use Availity multi-payer Web Portal first for all claims payment inquiries
If not successful, inquiries may be addressed through Customer Service (“CS”) for resolution [phone number is listed on back of the member’s ID card]
Escalation: In the event that the self-service tools and CS Reps are unable to provide your office with support, then request to speak with a CS Supervisor. A Reference No. will be provided for you to retain in future communications- it is extremely import to keep this Reference No. for future use
If no resolution is met after following these above steps, you may request the issue be entered into an Escalation Tool and the Provider Inquiry Resolution Team (PIRT) will follow up with you within 1 business day and follow through to completion
Process is designed to ensure you receive answers to claims inquiries
Visit BCBSGA website for more information
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20. BCBSGA Resources
The BCBSGA web site provides access to:
General information and answers to frequently asked questions
Medical Policies and Clinical UM Guidelines
BCBSHP HMO Physician Office Manual
Most up-to-date provider communications
Formulary information
Precertification Requirements
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21. QCPI Resources www.qcpi.org provides access to:
General information and answers to frequently asked questions about QCPI
Messages and notices about current incentive programs
QCPI Primary Care Physician Network Manual
provides access to:
QCPI’s incentive and self-reporting programs
To access QCPI’s websites, use your login/password. Your login is your firstname.lastname and your initial password was provided to you in your welcome letter
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