Kim’s Corner June 2011

*North Carolina Providers Only* BCBS State Health Plan

As you recall, we have been working with BCBS State Health Plan over the past few months  Several months ago, BCBS SHP began denying all non-emergency transports and issued requests for refunds/recoupments on those claims that were previously paid. Throughout these discussions, BCBS stated that a written policy would be developed to provide the ambulance community with consistent guidelines for coverage. I was notified today that this new policy will be available on their website and will be mailed to individual providers next week.

The policy will be effective for dates of service, July 1, 2011 and forward.  The great news is:  all previously refunded claims will be paid back to the provider of service, all open requests for refund will be voided.

Highlights of the new policy will be (the official policy will be mailed to you):

  • Applies to State Health Plan only.  Commercial Plans were not affected.
  • The following non-emergency transports will be covered, as long as medical necessity is met:
    • When Destination is Hospital (from residence, assisted living, skilled nursing facilities)
    • Hospital to Hospital and Hospital to Skilled Nursing Facility
    • Dialysis Transports (only when Medicare is primary)
  • All other non-emergency transports will be denied as not medically necessary
    • These claims may be appealed with a copy of the Patient Care Report and may be covered on a case-by-case basis
  • Physician Office Transports will never be covered unless an intermittent stop at the physician’s office when the destination is hospital (similar to Medicare’s policy)
    • Non-emergency transports to and from Physician’s Offices are never covered and will not be overturned upon appeal

**Very Important**:  Participating BCBS Providers will be required to have the patient sign a Service Specific Waiver in order for the patient to be financially responsible for the non-covered transport.

I will providing a more detailed review of the new BCBS State Health Plan Policy during the Reimbursement Track in Asheville.

Feel free to contact me if you have any further questions.

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