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

Providers ending their participation in a Blue Cross Blue Shield of Michigan plan or network or who have been terminated from a Blue Cross plan or network with or without cause (for a non-quality or non-fraud related reason) have the option to continue treating members subject to the conditions stated below. At Blue Cross, this process is referred to as Continuity of Care. This includes primary care providers and specialists affiliated with the TRUST, EPO or BPP networks and ancillary providers that participate in the Blue Cross Traditional network.

Note: The option to continue care doesn’t apply to practitioners whose participation in a Blue Cross plan or network ends because 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

Patients in an “active course of treatment” until the treatment is complete or for 90 days from the termination date, whichever is shorter. Active course of treatment is described as:

• An ongoing course of treatment for a life-threatening condition
• An ongoing course of treatment for serious acute condition
• The second or third trimester of pregnancy, through the postpartum period (if member is in the second or third trimester at the time of contract termination)
• An ongoing course of treatment for a health condition for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes
• Terminal illness (care directly related to a diagnosed illness may continue for the remainder of the member’s life, if the member was diagnosed with the terminal illness prior to the date of contract termination)

Payment conditions

• As long as the approved continuity of care period is in effect, the practitioner is required to accept Blue Cross’ 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 suggested under 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 isn’t 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 CMS-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 the forms and correspondence listed 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.