Premier Blue

Frequently Asked Questions - Provider

1. How is Premier Blue marketed?

   Premier Blue - All services must be rendered or referred by the member's designated Primary Care Physician in order to receive the highest level of benefits. Services not rendered or coordinated by the PCP are the member's responsibility or are paid at a lower benefit level of self-referred.

   Premier Blue with Self-Referral Option - Members with the self-referral option may coordinate their own medical services at a reduced level of benefits.

   Premier Blue Access Option - This is an option in which the member is not required to have a designated PCP and can obtain services without a referral, but a provider within the Premier Blue network must render the service.

2. Who is eligible to become a PCP?

   Only those medical doctors or doctors of osteopathy whose specialty is family practice, general practice, pediatrics, or internal medicine are eligible to be a primary care physician in the Premier Blue network.

3. What documents are required to become a participating provider in the Premier Blue Network?

   To become a Premier Blue provider, physicians must complete an application by signing a Primary Care Physician or Referral Physician Provider Agreement. The Managed Care Professional Credentialing Application and Addendum must also be completed. Your Professional Relations Representative must complete an Office Site Assessment and the physician must score at least 80 percent or greater in all areas.

4. Are there practice restrictions available in the Premier Blue program for PCPs, and if so, what are they?

   Yes, the following are practice restrictions available in the Premier Blue Program.
   
   Open = accepting new patients
   Established patients only = accepting patients established within the group/practice
   Practice full = not accepting new or established patients transferring to either of these programs

   Requests for practice restrictions must be sent to your Professional Relations Representative in writing. Requests become effective the first of the month following the receipt plus 60 days. For example: BCBSKS receives the request on March 18, and then the practice restriction would become effective June 1.

5. Can a PCP dismiss a patient from his/her practice?

   Yes. Effective Jan. 1, 2002, the Intercept Committee will no longer require that patient dismissals be reviewed prior to sending the member a dismissal letter. As of Jan. 1, 2002, when a PCP dismisses a member, a copy of the dismissal letter must be sent to BCBSKS, Attention CC: 466 E2, 1133 SW Topeka Blvd., Topeka, KS, 66629-0001, or fax to 785-290-0709 at the same time the dismissal letter is sent to the member. This notification will allow Blue Cross and Blue Shield of Kansas to correspond with the member and coordinate selection of a new PCP.

6. Are referrals required?

   Yes except for the following:

   1. The initial treatment of a life-threatening emergency.
   2. The initial treatment of an urgent condition that occurs out of the service area.
   3. Care provided by the PCP's covering physician.
   4. Maternity service (gynecological services require a referral). However, a contracting Premier Blue provider needs to be utilized.
   5. Abortions. However, a contracting Premier Blue provider needs to be utilized.
   6. Sterilizations. However, a contracting Premier Blue provider needs to be utilized.
   7. Dental services (to the extent the member's policy provides dental coverage, i.e. accidental injury and oral surgical procedures).
   8. Newborn services for the first 31 days.
   9. Ambulance services for life-threatening conditions.
   10. Routine eye exams to determine the need for vision correction. However, a contracting Premier Blue provider needs to be utilized.
   11. Childhood immunizations from birth to age 18.
   12. TB tests/treatment, in conjunction with childhood immunizations for patients from birth to age 18 OR, if the service is provided by the county health department without restriction on age.
   13. Well Woman Care. However, a contracting Premier Blue provider needs to be utilized.
   14. Lab and Radiology when the PCP's name appears on the performing provider's claim as the "referring physician."
       
7. How are mental health services handled for Premier Blue members?

   HMS/Value Options will coordinate both inpatient and outpatient mental health care and outpatient substance abuse care. PCPs cannot authorize care. Members must contact HMS/Value Options at 1-800-952-5906.

8. Are pre-certifications required for inpatient services?

   Yes. Premier Blue requires pre-certification for all inpatient services.

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