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Non payment from Blue Plus plan - Restricted Recipient Program ???

sfoster 1 year ago in Payments/ERA Modules updated 1 year ago 2

Has anyone else seen denied claims from BCBS pmap (LMN... policy) and been told it is because the member is in a Restricted Recipient Program? 

This note is from MNits regarding this type of policy/program:

Restricted Recipient Program:

Some MHCP recipients are required to receive the following services from specific providers: Inpatient Hospital, Pharmacy, Physician Services, Mental Health, Outpatient.

The frustrating thing is that you do not know the member has this "restriction" unless you actually call BCBS or first check Availity and then check MNits. It is NOT indicated on Availity at all. So when a client gives you their BCBS pmap card and you check Availity for active coverage, you then have look at the image of the card to get their MA #, then login to MNits to see if they have this type of program. 

Also, the BCBS rep told me authorization is NOT an option for this type of program and our only option for possible payment would be to appeal for medical necessity. 

Help anyone! Thanks, Sara

We also ran into this and what we found out is the receipient has to have his provider sign a form stating that the provider ok's the service whether it be medication management, therapy or Substance Use programs.  Once BCBS receives this from the provider then your practice is added to the list of providers that are approved to see the client.  The primary provider has to initiate this.  Since then we haven't had an issue with payments for the clients we've had.  Hope that helps.  We had the client do this immediately so we didn't have to appeal. 

Kelly, Thank you so much for your response! One more quick question from whom did you get the form and were you able to fax it to BCBS?

Thanks!