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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.
Participation in BlueChoice is a prerequisite.
Physicians and professional providers must meet BlueChoice credentialing criteria. Review components included in the current BlueChoice credentialing process are: physician/professional provider qualifications to practice in a specialty; actions of licensing boards; actions of medical staff committee on clinical privileges; quality of care issues; member complaints; malpractice cases; utilization data; Medicare/Medicaid sanctions; and information from the National Practitioner Data Bank and the Healthcare Integrity Protection Data Bank.
Physicians and professional providers must also meet additional BlueChoice Solutions credentialing criteria. Components include a risk adjusted cost index (RACI) below the threshold and a minimum number of qualified episodes. Meeting the threshold RACI and having the minimum number of qualified episodes does not guarantee participation in the BlueChoice Solutions network. When physicians/professional providers have exceptionally high utilization, detailed claims review is performed by experienced nurses and like-specialty peer review is obtained as needed. Physicians/professional providers with utilization patterns that stand out from their peers are sent letters that explain the specific concerns and the “drivers” behind them. These physicians/professional providers may not be eligible to participate in the BlueChoice Solutions network.
Effective for January 1, 2007 participation, adherence to Evidence Based Measures Indicators was included in the participation criteria for the BlueChoice Solutions network. BCBSTX uses Evidence Based Measures Indicators from Health Benchmarks Inc. (HBI) to assess important aspects of clinical care based on claims and enrollment data. To access a complete list of the Evidence Based Measures Indicators and for additional information click here. Overall performance across indicators will be used as additional screening criteria in determining eligibility. The evaluation will apply to physicians meeting threshold numbers of qualified denominator events.
Eligibility to participate in BlueChoice Solutions is reevaluated annually.
What is BlueChoice Solutions?
What is the Risk Adjusted Cost Index (RACI)?
How do I find my RACI?
What are Evidence Based Measures Indicators?
What if I Have Additional Questions?
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