Blue Review
A Provider Publication
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July 2021

Closing Gaps in Care for Group Medicare Advantage (MA) Members

The Blue Cross and Blue Shield (BCBS) National Coordination of Care program is again serving Blue Cross Group Medicare Advantage (PPO)SM (Group MA PPO) members. The program paused during the global pandemic. As we told you in January 2020, the program supports continuity of care for all BCBS Group MA PPO members.

What This Means for Medicare Providers

Blue Cross and Blue Shield of New Mexico (BCBSNM) will work with you to help close gaps in care for BCBSNM and other BCBS Group MA PPO members. If we need medical records, you won’t receive requests from multiple BCBS plans or their vendors. You will receive requests only from BCBSNM or our vendor, Change Healthcare. We may request medical records for:

  • Risk adjustment gaps related to claims submitted to BCBSNM
  • Healthcare Effectiveness Data and Information Set (HEDIS®) measures
  • Centers for Medicare & Medicaid Services (CMS) Star Ratings

Important Reminders

  • Respond quickly to requests related to risk adjustment, HEDIS and other government-required activities as your contract requires.
  • You don’t need patient‑authorized information releases to fulfill medical records requests and risk adjustment gaps through this program.
  • Use the Availity® Provider Portal or your preferred vendor to verify BCBSNM and other BCBS members’ eligibility and benefits before every appointment. Eligibility and benefit quotes include:
    • Membership verification
    • Coverage status
    • Prior authorization requirements
    • Provider’s network status for the patient’s policy
    • Applicable copayment, coinsurance and deductible amounts
  • Ask to see the member’s ID card and a photo ID to help guard against medical identity theft.
  • Notify members that they may be billed directly when services may not be covered.

Questions? Call the Customer Service number on the member’s ID card.

Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.

HEDIS is a registered trademark of the National Committee for Quality Assurance.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by the vendor, you should contact the vendor directly.

Change Healthcare is an independent third-party vendor that is solely responsible for the products or services they offer. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by independent third-party vendors. If you have any questions regarding the services they offer, you should contact the vendor directly.