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Avoid denied claims: custom benefits and eligibility checks
March 27, 2018

This article is intended for acute care hospitals and facilities that perform specialty care services.

More and more, employers are creating customized health benefit designs that specify where their employees can get certain types of care. These benefit designs may steer them to certain facilities or providers to get coverage, or to get coverage with reduced out-of-pocket costs.

That’s why it’s important to get authorization and check benefits and eligibility before scheduling and performing a member’s service.

How to avoid denied claims
Because custom benefit designs can be very specific about where a member can go to get certain covered services, always remember to:

  • Get authorization for services from the member’s health plan. A Blue Cross Blue Shield of Massachusetts authorization approves medical necessity only. It does not tell you whether the member’s plan covers the service and if they are eligible.  
  • Check eligibility before performing the service.
    • For tips on checking eligibility, see this article we published in December 2017.
    • Please take extra care to ensure that the member has benefits available for the specific service.
    • Be sure to check eligibility again on the date of service.

Example: Blue Distinction Specialty Care
Custom benefit designs that steer members to Blue Distinction Centers are on the rise. What’s Blue Distinction? This specialty care program identifies facilities nationwide which have met a consistent set of quality and cost criteria for care in eight specialty services, including:

  • Bariatric surgery
  • Cardiac care
  • Cancer care (coming soon-effective 1/1/19)
  • Knee and hip replacement
  • Maternity care
  • Spine surgery
  • Transplants
  • Fertility care (coming soon-effective 1/1/19)

Two different designations
Hospitals that have demonstrated quality, expertise, and better patient results in delivering specialty care may receive the Blue Distinction Centers® designation. Hospitals that have shown quality, expertise, health results, and cost-efficiency in delivering specialty care are designated as Blue Distinction Centers+.

Employers can then use Blue Distinction designations to develop benefit designs that:

  • Can be customized by specialty (bariatric surgery, cancer care) or designation level (Blue Distinction Center or Blue Distinction Center+)
  • Require a member to receive certain specialty services at a Blue Distinction Center for coverage
  • Have different member cost, based on where the member receives care

Example: 

  • Employer A’s health plan may cover bariatric surgery, but ONLY when performed in a Blue Distinction Center+ (Blue Distinction “plus”). If one of their employees goes to a facility that is not Blue Distinction+, the service may not be covered at all.
  • Employer B’s health plan may cover bariatric surgery also, but have a tiered benefit that “steers” members toward a Blue Distinction Center, but allows them to get the surgery at a facility that is not part of Blue Distinction Specialty Care at a higher member cost.

Questions
For questions about Blue Distinction, authorization, or eligibility, please call Network Management & Credentialing Services at 1-800-316-BLUE (2583).

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