Posted in BCBS (Various States), Training, Updates

BCBS Staying compliant with after hours messaging for Behavioral health providers

Is your Behavioral Health Practice Compliant?

In the recent assessment by a third party Vendor-North American Testing Organization based in California, for the third Q of 2021, it was found that most of the Empire BlueCross BlueShield (“Empire”) plans assessed fell short of the expectation of having a live person or a directive in place after hours.


The main challenges that the third party vendor had were the following:

  • inaccurate provider information in Empire’s demographic database to allow assessment of the after-hours messaging
  • no voicemail or messaging at all
  • voicemail not reflecting the practitioner’s name
  • calls being auto forwarded with no identification, no voicemail or messaging

What does this mean for BCBS members?

In an annual member survery, BCBS members have indicated that when they needed advice, they are unable to to reach the provider office for urgent instructions.


In order to be compliant, as per Provider Manual, providers need to have the following:

  • Emergency situations : Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
  • Emergent / Urgent situations: Compliant responses for urgent needs after hours:
    • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
    • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
    • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect.)

Examples of non-compliant responses include the following:

Non-compliant responses for urgent needs after hours include:

  • No provisions for after hour accessibility.
  • Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

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Posted in Insurance, Training, Updates

Anthem Medi-Cal: Hospital Reimbursement Policy Update- 05/01/21

Currently Anthem Medi-Cal reimburses for services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

However, Emergency and observation services are included in the inpatient reimbursement and, therefore, are not separately reimbursable expenses when performed within 24 hours prior to and including the day of the member’s admission.

Effective 05/01/21- Anthem Medi-Cal the following changes will take effect:

  1. For admitting hospitals: preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission. Therefore, they are not separately reimbursable expenses.
  2. Anthem will not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services:
  • Ambulance services
  • Maintenance renal dialysis services
  • Services provided by:
    • Skilled nursing facilities
    • Home health agencies
    • Hospices
  • Unrelated non-diagnostic services

If you have more information please visit:  https://mediproviders.anthem.com/ca. and review Preadmission Services for Inpatient Stays reimbursement policy