Starting on 04/01/21 and thereafter the participating provider must provide advance notification to the member so the member may choose whether to oppose or approve the use of a non-participating provider for the service or procedure.
Below are several examples that would apply to this policy: (source : Anthem BCBS Administrative policy: Use of a Non-Participating Provider Advance Patient Notice Policy)
- A participating physician draws a member’s blood in his or her office but sends the sample to a nonparticipating laboratory for processing.
- A participating surgeon involves a non-participating assistant surgeon in a member’s surgery.
- A member is referred to a non-participating facility such as an ambulatory surgical center, endoscopy suite or office based surgical suite. (Often a member mistakenly believes that the centers or suite is participating in Anthem’s network because: i) his/her participating physician recommended/referred toit; ii) his/her participating physician or the physician’s partner is the individual performing the procedure or surgery at the facility; or iii) the surgical suite appears to be an extension of the participating physician’s office.)
- Durable Medical Equipment (“DME”) order placements are facilitated by a participating physician’s office and the office arranges with, or gives the member instructions to contact, a specific DME provider that is non-participating.
The notice must be provided, completed, and dated by the member, and retained in the member’s medical file a minimum of seven (7) days in advance of the procedure or service.
In addition, providers or facilities who are instructed to provide copies of signed advance notice policies as the result of an audit will now be required to respond with the required information within fifteen (15) days.
This policy will continue to apply to both facilities and professional providers.
Source: Anthem BCBS (CT) provider communications.
To read the full Administrative policy, please click here on the link.
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