Blue Cross extends continuity of care for members whose practitioners leave PPO network

Practitioners, including M.D.s, D.O.s and D.P.M.s, who decide to leave Blue Cross Blue Shield of Michigan’s TRUST, Metro Detroit Exclusive Provider Organization and Blue Preferred Plus^SM networks can care for their members as long as a practitioner’s participation in the network didn’t end as a result of fraud or failure to meet quality standards.

Practitioners who want to continue a member’s care after they leave the TRUST, EPO and BPP networks are required by state law to provide members with a written notice within 15 days of the date they leave the provider network. This notice may be posted in the practitioner’s office or sent to members in a card or letter informing them of the practitioner’s intent to leave the network.

If a member wants to continue care after his or her practitioner leaves the network and enters into a written continuity of care arrangement, the following limitations apply:

Coverage limitations

• For general care, BCBSM will provide coverage for 90 days from the date the 15-day notice is sent out as long as the member has received services from the disaffiliated practitioner at least twice in the last 12 months and is in a current period of active treatment. An active course of treatment is a situation for which a disruption of the current course of treatment could cause a recurrence or worsening of the condition under treatment and interfere with anticipated outcomes

• For maternity care, BCBSM will provide coverage if the member is in the second or third trimester of pregnancy at the time the practitioner leaves the network. This coverage will continue through the postpartum period

• For treatment directly related to a terminal illness diagnosed before the practitioner left the network, BCBSM will provide coverage for the remainder of the member’s life

Payment conditions

• As long as the approved continuity of care period is in effect, the practitioner is required to accept BCBSM’s payment as payment in full, less any in-network copays or deductibles that the member may be required to pay.

• The above rules apply only to members who were in the practitioner’s care before his or her termination from the network. Continuation beyond the designated times will result in out-of-pocket expenses for the member in the form of out-of-network copays and deductibles.

• Continuity of care is not automatic and must be initiated by the practitioner. When billing TRUST/BPP members after the termination is effective, the practitioner will need to include for each claim submission:
• A HCFA 1500 paper claim form
• A copy of the continuity of care arrangement letter, signed by both the patient or subscriber and the provider
• Supporting medical records

• Practitioners should submit all of the forms and correspondence above to:
  Attn: Continuity of Care Senior Analyst
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd MC 607A
  Detroit, MI 48226-9942

For EPO practitioners

• EPO claims for continuity of care don’t follow the claims submission guidelines listed above. If you have any questions regarding the process, refer to your provider manual