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BlueCompare Inquiries and Reviews

Where to Direct BlueCompare Inquiries

Inquiries regarding BlueCompareSM methodology, interpretation of scores, your tax ID number or specialty designation should be directed to your local Professional Provider Network office. You should receive a response within 30 days of our receipt of the inquiry.

General inquiries and requests for reports are not considered by Blue Cross and Blue Sheild of Texas (BCBSTX) as formal requests for review. Requests for review must follow the procedure outlined below.

If you are not satisfied with your BlueCompare Evidence information, you have the right to request a review.

The Evidence Based Measures (EBM)/Physician Quality Measurement (PQM) Review Process

The Review Process For Physicians Who Did Not Meet the Threshold for Recognition

Written Response Required:
If you wish to utilize the written fair reconsideration process, you must submit a written response regarding your performance by July 7, 2014.  Include supporting patient documentation and/or a Performance Improvement Plan as described below.  Please understand that physicians participating in BCBSTX networks must cooperate with peer review activities.  We will refer physicians who fail to cooperate to a BCBSTX peer review committee for consideration of sanctions, which may include termination of the physician’s network participation contract.

Physicians Submitting Supporting Patient Documentation:
Initial Review:  If the physician sends documentation that demonstrates or indicates that services were provided to the patient(s), or that services do not apply to the patient(s), it is reviewed by a BCBSTX nurse.  The information is entered into a database that re-scores the data and the information will update the Evidence Based Measures (EBM) and Physician Quality Measurement (PQM) data. If this results in a score change that meets the threshold for expected performance on EBM, the BCBSTX Provider Finder® will be updated with a blue ribbon and the National Doctor and Hospital FinderSM BPR symbol and PQM detail measurement data will be updated. We send a letter to the physician about the review outcome.

If the initial review does not result in a score change, the case is reviewed by the Evidence Based Measures Internal Review Committee (EBMIRC) which is a committee comprised of representatives from BCBSTX.  If the EBMIRC determines that the case warrants a change in the physician’s results, BCBSTX Provider Finder will be updated with a blue ribbon and the BPR symbol will be displayed in the National Doctor and Hospital Finder. A letter is sent to the physician informing them of the review outcome.

If the review does not result in a change, the physician is given the option to request a second level review by a panel of participating physicians, either the Texas Medical Advisory Committee (TMAC) or the Texas Peer Review Committee (TPRC) of BCBSTX.  Both committees’ members are practicing physicians and other health care providers who also participate in networks serving members of BCBSTX health programs.

Second-level Review: If a second-level review is requested by a physician, the documentation provided by the physician is presented to either the TMAC or TPRC. If the committee determines that the case warrants a change in the physician’s results, BCBSTX Provider Finder will be updated with a blue ribbon and the BPR symbol will be displayed in the National Doctor and Hospital Finder. We send a letter to the physician about the review outcome.

If the review does not result in a change, the second-level review is the final step in the written fair reconsideration process.

Please note: For the 2014 BlueCompare update, we will complete both the initial and second level reviews on all BlueCompare review requests received on or before July 7, 2014 prior to updating the individual physician’s BlueCompare information on the Web site.

Submitting a Performance Improvement Plan (PIP) in Lieu of Patient Documentation:
If a PIP is submitted, it is presented to the EBMIRC which is a committee comprised of BCBSTX representatives. If the EBMIRC recommends a change in the physician’s results, Provider Finder will be updated with a blue ribbon and the BPR symbol will be displayed in the National Doctor and Hospital Finder. We send a letter to the physician about the review outcome.

If the review does not result in a change, the physician is given the option to request a second level review by a panel of participating physicians, either the Texas Medical Advisory Committee (TMAC) or the Texas Peer Review Committee (TPRC).  Both committees’ members are practicing physicians and other health care providers who also participate in networks serving members of BCBSTX health programs.

Second level Review: If a physician requests a second level review, all documentation provided by the physician is presented to either the TMAC or TPRC. If the committee recommends a change in the physician’s results, BCBSTX Provider Finder will be updated with a blue ribbon and the BPR symbol will be displayed in the National Doctor and Hospital Finder. We send a letter to the physician about the review outcome.

If the review does not result in a change, the second level review is the final step in the written fair reconsideration process.

Please note: For the 2014 BlueCompare update, we will complete both the initial and second level reviews on all BlueCompare review requests received on or before July 7, 2014 prior to updating the individual physician’s BlueCompare information on the Web site.

Information to Submit for a Review and Where to Send the Review Request:
Send your written response and/or performance improvement plan to:

Kathleen Leifker, R.N.
1001 E. Lookout Drive, Tower B.11
Richardson, Texas 75082

Or via email to Kathleen_Leifker@bcbstx.com

Requests should include:

  • the date of the request
  • your name and address
  • your Practice Evaluation ID Number (found on the BlueCompare letter and reports)
  • a statement of the reason(s) for requesting a review
  • supporting documentation for patients on the EBM Member List that indicates services were completed or that a measure did not apply to the patient. 

If you are unable to provide this supporting documentation you must submit a Performance Improvement Plan as described below.          

Submitting a Performance Improvement Plan (PIP):
If you submit a Performance Improvement Plan, it must clearly state the actions you will take to improve your performance. Your plan must include at least one of the following:

  • A copy of any flow sheets that are used to track patient compliance/noncompliance, or
  • Reports from an Electronic Medical Record system or Quality Improvement Program demonstrating the performance in your practice on the measures shown on your EBM Summary Report; or
  • Completed documents from the AAFP METRIC or ACP PIM or AMA PCPI modules for these measures.

All the information submitted will be evaluated. You will be notified of the results.  If you submit a PIP by July 7, 2014, the results of that review will be reflected in the 2014 BlueCompare online update.

The Review Process For Physicians Who Received a Blue Ribbon

If the physician sends documentation showing services were provided to the patient(s), or that services do not apply to the patient(s), the information is reviewed by a BCBSTX nurse.  The information is entered into a database and will update the PQM data for display. We send a letter to the physician about the review outcome.

Information to Submit for a Review and Where to Send the Review Request:
If you do not feel that your EBM reports accurately represent your practice’s performance for the selected measures, you may request a review of your updated BlueCompare EBM information by sending a written request to:

Kathleen Leifker, R.N.
1001 E. Lookout Drive, Tower B.11
Richardson, Texas 75082

Or via email to Kathleen_Leifker@bcbstx.com

Requests should include:

  • the date of the request
  • your name and address
  • your Practice Evaluation ID Number (found on the BlueCompare letter and reports)
  • a statement of the reason(s) for requesting a review
  • supporting documentation for patients on the EBM Member List that indicates services were completed or that a measure did not apply to the patient. 

If you submit additional documentation, the information submitted will be evaluated. If changes are necessary, we will update our system and the information will be retained for future evaluations.

Requesting a Face to Face or Telephonic Hearing:

In addition to the written fair reconsideration process described above, within 30 days of the physician receiving written notice of the EBM/BPR/PQM rating, the physician may request a reconsideration proceeding:

  • By teleconference, at an agreed upon time; or
  • in person at the BCBSTX Headquarters building, located at 1001 E. Lookout, Richardson, TX 75082, at an agreed upon time or between the hours of 8:00 AM and 5:00 PM Monday through Friday

The physician may:

  • provide additional information for a determination by Blue Cross and Blue Shield of Texas,
  • have a representative participate in the reconsideration proceeding,
  • submit a written statement at the conclusion of the reconsideration proceeding.

Blue Cross and Blue Shield of Texas (BCBSTX) will

  • provide in writing the outcome of the reconsideration proceeding prior to making public the EBM/BPR/PQM rating.

Requests should include:

  • the date of the request
  • your name and address
  • your Practice Evaluation ID Number (found on the BlueCompare letter and reports)
  • supporting information the physician wants to submit prior to the review
  • a statement of the reason(s) for requesting a review
  • a contact name and phone number
  • the requests may be made by
    • fax: 972-766-1103
    • email: Kathleen_Leifker@bcbstx.com
    • by mail to Kathleen Leifker, R.N.
      1001. E. Lookout Drive, Tower B.11
      Richardson, TX 75082

View information on BlueCompare and BlueCompare Evidence Based Measures (EBM).

If you have questions regarding your participation, please contact your local Professional Provider Network office.

The Physician Cost Assessment (PCA) Review Process

Affected physicians who are dissatisfied with their PCA results have the right to request a review in writing. In addition to the written fair review reconsideration process, BCBSTX also provides a fair reconsideration proceeding.  Both processes are described below:

Written Fair Review Reconsideration Process

If you do not feel that your PCA reports accurately represent your practice’s performance, you may request a review of your PCA results by sending a written request to your local Professional Provider Network Office:

The Written Fair Reconsideration Review request should include:

  • the date of the request
  • your name and address
  • your Practice Evaluation ID Number (found on the PCA letter and reports)
  • supporting information you want to submit
  • a statement of the reason(s) for requesting a review
  • a contact name and phone number

If you submit additional documentation, the information submitted will be evaluated.   If the information you submit leads to a change to your PCA results, we will update our systems and notify you in writing of the review outcome.
If the review does not result in a change to your PCA results, you have the option to request a second level review by a panel of participating physicians, either the Texas Medical Advisory Committee (TMAC) or the Texas Peer Review Committee (TPRC) of Blue Cross and Blue Shield of Texas (BCBSTX).  Both committees’ members are practicing physicians and other health care providers who also participate in networks serving members of BCBSTX health programs.

Second-level Review: The documentation you provide will be presented to either the TMAC or TPRC. If the committee determines that the case warrants a change to your PCA results, Provider Finder® will be updated with a second blue ribbon for cost efficiency. We will send you a letter with the review outcome.

If the review does not result in a change to your PCA results, the second-level review is the final step in the written fair review reconsideration process.

Fair Reconsideration Proceeding:

In addition to the written fair reconsideration review process described above, within 30 days of you receiving written notice of the PCA results, you may request a fair reconsideration proceeding:

  • By teleconference, at an agreed upon time; or
  • in person at the BCBSTX Headquarters building, located at 1001 E. Lookout Drive, Richardson, TX 75082, at an agreed upon time or between the hours of 8:00 AM and 5:00 PM Monday through Friday

You may:

  • provide additional information for a determination by Blue Cross and Blue Shield of Texas,
  • have a representative participate in the reconsideration proceeding,
  • submit a written statement at the conclusion of the reconsideration proceeding.

Fair Reconsideration Proceeding Requests should include:

  • the date of the request
  • your name and address
  • your Practice Evaluation ID Number (found on the PCA letter and reports)
  • supporting information you want to submit prior to the reconsideration hearing
  • a statement of the reason(s) for requesting a Reconsideration Proceeding
  • a contact name and phone number
  • the requests may be made by
    • fax: 972-766-1103 to Kathleen Leifker, R.N.
    • email: Kathleen_Leifker@bcbstx.com
    • by mail to Kathleen Leifker, R.N.
      1001. E. Lookout Drive, Tower B.11
      Richardson, TX 75082

Blue Cross and Blue Shield of Texas (BCBSTX) will provide in writing the outcome of the reconsideration proceeding, including the specific reason(s) for the final determination prior to publishing the BlueCompare cost performance symbol.

 
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