| Frequently Asked Questions: Medical & Utilization Management |
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Please note that the information on these pages is historical and is to be used for informational purposes only. We have discontinued the use of the risk adjusted cost index (RACI) to determine eligibility for the BlueChoice Solutions High Performance Network until national standards are more clear and we assess our alternatives.
| Q: |
Are the policies, procedures and guidelines for BlueChoice Solutions different than the policies, procedures and guidelines for BlueChoice? |
| A: |
No. The policies, procedures and guidelines for the BlueChoice Solutions network are the same as the policies, procedures and guidelines for the BlueChoice network. The policies, procedures and guidelines can be found in the most current version of the BlueChoice Provider Manual (password is “manual”). However, the credentialing criteria guidelines and policies for BlueChoice Solutions have been enhanced to include Risk Adjusted Cost Indices (RACI), Evidence Based Measures Indicators and screening of appropriateness of utilization or coding.
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| Q: |
Does the BlueChoice Solutions network require a referral for members to see the specialist? |
| A: |
It depends on the member’s benefit plan.
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| Q: |
Are the BlueChoice Solutions referral and precertification processes different? |
| A: |
The BlueChoice Solutions referral and precertification process is the same as the current BlueChoice referral and precertification process.
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| Q: |
I am a PCP. What do I do if I need to refer a patient to see a physician/professional provider with a specialty type that is not available in the BlueChoice Solutions network? |
| A: |
If there is not a specialist with a particular specialty type in the BlueChoice Solutions network, you will need to contact the Utilization Management (UM) Department at 1-800-441-9188, select 1, then select 3 to obtain approval for an out-of-network referral.
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