Roles & Responsibilities of Health Provider Contractors in Vermont
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives. We do not penalize providers for discussing medically necessary or appropriate care with members.
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services, counseling or referrals.
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow-up and that members receive training in self-care and other measures they may take to promote their own health.
Coordination of Care
VHP and TVHP members select primary care physicians (PCPs) responsible for coordinating care. Providers are responsible for requesting information necessary to provide care from other treating practitioners and providers. When a member is referred to a specialist or other provider, we request the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the member's status.
Primary Care Practitioner Coordinates Care
Except for self-referred benefits, in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP.
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation, determining the diagnosis, and recommending ongoing treatment for the patient. While none of our Plans (except the New England Health Plan) require referrals, we encourage members to coordinate all care through their PCPs.
Specialty Provider Responsibilities
Specialty providers are responsible for:
- Communicating findings surrounding a patient to the patient's PCP to ensure that the PCP is informed of the member's status.
- Obtaining prior approval as appropriate.
Continuity of Care
BCBSVT and TVHP support continuity of care. We allow standing referrals to specialists for members with life threatening, degenerative or disabling conditions. A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan, accept the Plan's payment rates and adhere to the Plan's credentialing and performance requirements. A request for a specialist to act as his or her PCP must come from the patient, and our medical director must review and approve the request.
Providers may contact the customer service unit to initiate a request for a standing referral.
A pregnant woman in her second or third trimester enrolling in a managed care plan can continue to obtain care from their current provider if she is out-of-network until completion of postpartum care is the provider agrees to specific conditions.
A new member with life threatening, disabling or degenerative conditions with an ongoing course of treatment with an out-of-network provider may see this provider for 60 days after enrollment or until accepted by a new provider. Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the person's functional abilities. Our medical director must review and approve the request.
Confidentiality and Accuracy of Member Records
Providers are required to:
- Maintain confidentiality of member-specific information from medical records and information received from other providers. This information may not be disclosed to third parties without written consent of the member. Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws, court orders or subpoenas. Unauthorized individuals must not have access to or alter patient records.
- Maintain the records and information in an accurate and timely manner, ensuring that members have timely access to their records.
- Abide by all federal and state laws regarding confidentiality and disclosure for mental health records, medical records, and other health and member information.
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization), their providers, contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes. Medical Record Audits may include the review of financial records, contracts, medical records, and patient care documentation to assess quality of care, credentialing and utilization.
Billing of Members
Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services. Providers will not bill members for amounts other than applicable co-payments, coinsurance or deductibles. We encourage providers to use their remittance advices as the source of member liability for collection of deductibles and coinsurance and bill members. Deductibles and coinsurance, however, can be billed to the member at the point of service, prior to rendering of service(s). In order to bill for these liabilities, providers must call our Customer Service Department to ensure the correct collection amount. If the member liabilities are reduced after receipt of the remittance advice, the provider must provide a quick turn-around in refunding the member any amounts due.
In certain circumstances, a provider may bill the member for non-covered services. In these cases, the collection should occur after you receive the remittance advice which reports the service as non-covered and shows the amount due from the member.
We suggest that you explain the cost of a non-covered service to the member and get the member's signature on an acknowledgement form before you provide non-covered services.
To verify if a service is covered, you may contact the appropriate customer service center.
After Hours Phone Coverage
BCBSVT/TVHP requires that primary care practitioners (i.e., internal medicine, general practice, family practice and pediatricians) and OBGYNs provide 24-hour, 7-days-a-week access to members by means of an on-call or referral system. Integral to ensuring 24-hour coverage is members' ability to contact their primary care physician and/or OBGYN after regular business hours, including lunch or other breaks during the day. After-hours telephone calls from members should be returned within one hour of receipt.
For guidelines on acceptable after-hours phone coverage, please refer to page 17 of the Provider Manual.
BCBSVT/TVHP monitors access to after-hours care through periodic audits. The Plan places calls to providers' offices to verify acceptable after-hours practices are in place. The Plan will contact providers not in compliance and work with those practices to develop plans of corrective action.
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring, you need to report it to the fraud hotline at (800) 337-8440. Calls to the hotline are confidential. Each call to the hotline is investigated and tracked for an accurate outcome.
Provider Initiated Audit
Written notification needs to be sent to the assigned Provider Relations Consultant 30 days prior to the initiation of the audit. The Provider Relations Consultant will contact the provider group and coordinate the details specific to completing the audit, such as the date, the format of the document and other required information.
Primary Care and OBGYN Services
BCBSVT/TVHP include the specialties of general practice, family practice, internal medicine and pediatrics in their definitions of Primary Care Physicians. BCBSVT/TVHP monitors compliance with the standards described below. We use member complaints, disenrollments, appeals, member satisfaction surveys and after-hours telephone surveys to monitor compliance. If a provider does not meet one of these standards, we will work with the provider to develop and implement an improvement plan. The following standards for access apply to care provided in an office setting:
- Access to medical care must be provided 24 hours a day, seven days a week.
- Appointments for routine preventive examinations, such as health maintenance exams, must be available within 90 days with the first available practitioner in a group practice.
- Appointments for routine primary care (primary care for non-urgent symptomatic conditions) must be available within two weeks.
Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of sufficient severity, including severe pain, that the absence of medical attention within 24 hours could be reasonably expected by a prudent layperson who possesses an average knowledge of health and medicine to result in:
- placing the member's physical or mental health in serious jeopardy;
- or serious impairment to bodily functions;
- or serious dysfunction of any bodily organ or part).
- Appointments for non-urgent care needs must be available within two weeks of a request (excluding routine preventive care).
- Emergency care must be available immediately.
- Routine laboratory and other routine care must be available within 30 days.
- Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment. If wait is expected to exceed 15 minutes beyond the scheduled appointment, the office notifies the patient and offers to schedule an alternative appointment.
- Waiting to get a routine prescription renewal (paper or call in to patient's pharmacy) shall not exceed three days.
- Call-back time to patient for a non-urgent problem shall not exceed 24 hours.
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians). The State of Vermont Department of Banking, Insurance, Securities, and Health Care Administration (BISHCA) require BCBSVT and TVHP to monitor specialists' compliance with the standards described below. We use member complaints, disenrollments, appeals, member satisfaction surveys and after hours telephone surveys to monitor compliance. The following standards for access apply to care provided in an office setting:
- Appointments for non-urgent symptomatic office visits must be available within two weeks.
- Appointments for emergency care (i.e. for accidental injury or a medical emergency) must be available immediately in the practitioner's office or referred to an emergency facility.