April 2018 

Working Together to Improve the Member-Provider Experience: Choosing the Best Direction

Blue Cross and Blue Shield of New Mexico (BCBSNM) is focused on improving our members’ experience when they access care. On occasion, a member or their representative may call BCBSNM to voice concerns and/or dissatisfaction with a provider or care received. The BCBSNM Quality and Accreditation Department is responsible for processing complaints from commercial and marketplace members regarding the quality of care and/or the quality of service that they receive from their BCBSNM participating providers. 

These quality-of-service and quality-of-care complaints are investigated and tracked to identify trends and best practices to improve the member-provider experience. The complaint investigation process involves reaching out to providers and may also involve collaboration with other BCBSNM departments such as network services, provider relations and/or claims processing.  

BCBSNM will publish a series of articles throughout this year to address some of our members’ most frequent concerns and remind providers of some of their related contractual obligations.  We hope that we can work together with you and your staff to improve the care that you furnish to your patients (our members).

The first member concern that we will address is: “Can my doctor refer me to any provider or facility of his/her choice?” 

As of the date of publication, referrals, routine or otherwise, are not required by BCBSNM.  If a contracted provider chooses to make a referral, however, the provider’s contract with BCBSNM states the provider’s obligation to refer members to other contracted providers so that out-of-pocket costs are limited and maximum benefits from their health plan are received. 

For BCBSNM members with health plans that do not have out-of-network benefits, prior authorization from BCBSNM is required for coverage of non-emergency services furnished by out-of-network providers. Even for members with health plans that include out-of-network benefits, contracted providers are required to refer members to other contracted providers to maximize their benefits; however, prior authorization is not required for such a member to see a non-contracted provider if they so choose (other prior authorization requirements continue to apply).

The Blues Provider Reference Manual (PRM) is part of your contract with BCBSNM. Sections from the PRM, including, but not necessarily limited to those excerpted for your ease of reference below, address your responsibilities regarding referrals to (the use of) contracted and non-contracted providers. Improved adherence to these responsibilities should help alleviate member complaints in this area.
Blues Provider Reference Manual 2018, Section 4, Professional Provider Responsibilities, 4.2 Primary Care Providers (PCPs)

For BCBSNM members, PCPs must:

• Use BCBSNM-contracted specialists, ancillary providers, hospitals, pharmacies, laboratories, radiologists, and behavioral health professionals and physicians. This means, for example, that a physician, professional provider, facility or ancillary provider who or which participates with BCBSNM is required to admit, transfer to, or refer BCBSNM Members to another professional provider, facility or ancillary provider who or which also participates with BCBSNM, except in emergencies or as may otherwise be required by applicable law.

Blues Provider Reference Manual 2018, Section 4, Professional Provider Responsibilities, 4.3.1 Specialist Responsibilities

BCBSNM requires PCPs to refer members to in-network specialists, unless they have preauthorization from the Medical Director or his or her designee to refer the member to an out-of-network specialist. Follow the referral and preauthorization procedures (see Blues Provider Reference Manual 2018, Section 10, Preauthorization).

For BCBSNM members, specialists must:

• Use BCBSNM-contracted ancillary providers, hospitals, pharmacies, laboratories, radiologists, and behavioral health professionals and physicians.

Blues Provider Reference Manual 2018, Section 10, Preauthorization, 10.1 Obtaining Preauthorization, Requests for Out-of-Network Providers

In the event medically necessary covered services are not reasonably available through professional Participating Providers, you, as a Participating Provider, should make a referral to an out-of-network professional. However, to be covered, referrals for out-of-network provider services for HMO members require preauthorization by BCBSNM. If not obtained, the out-of-network service will not be covered. BCBSNM’s Medical Director must review and approve these referrals before out-of-network services are scheduled or rendered.

These out-of-network referrals will only be preauthorized when a medically necessary covered service is not reasonably available through a Participating Provider.

Before BCBSNM may deny such a referral to an out-of-network physician or health care professional, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.

Below are some suggestions that may assist in referring members to appropriate providers and ultimately improve member-provider experiences:

1) Encourage your patients to be aware of their coverage, benefits and networks. Provider Finder, located at bcbsnm.com, can assist providers and members in identifying contracted practitioners and/or facilities for each BCBSNM health plan. Contracted providers should confirm another provider’s contracted status before referring a member to that other provider.

2) Encourage your patients to call a BCBSNM Customer Service Advocate (CSA) before services are furnished to verify whether a provider is in or out of the network for their health plan. Also, encourage your patients to directly ask the provider about the provider’s contracted status with BCBSNM.

Numbers for CSAs are found on the back of the member’s BCBSNM ID card. If a member does not have their BCBSNM card, they may call:

Commercial members: 1-800-432-0750      
Marketplace members: 1-866-236-1702 

3) BCBSNM Provider Network Representatives are available to assist contracted providers:
Monday - Friday, 8 a.m. to 4 p.m. Phone: (505) 837-8800 or toll free at 1-800-567-8540.
Provider Network Representatives can tell you if another provider is contracted with BCBSNM for your patient’s BCBSNM health plan.

By working together with BCBSNM, you can better refer your patients, our members, to appropriate providers for timely care and optimal use of their covered plan benefits.

Our next Blue Review article will explore member concerns regarding Durable Medical Equipment.