Name of Manual - Blue Cross and Blue Shield of Minnesota

Access Management
Programs (continued)
Integrated Health Management
Access management members/restricted recipients are members
who have used services at a frequency or amount that is not
medically necessary and/or who have obtained services in an
inappropriate manner.
Access management specialists in Integrated Health Management
review members’ medical and pharmacy claims for potential
restriction. Members who meet the access management program
criteria are assigned to a specific physician for the primary care
needs who, in turn, will coordinate all their care and medication
needs. The member will also be assigned to a single pharmacy and
a single hospital. Access to specialty care may be discussed with
the access manager assigned to the member. Access management
program restriction is for 24 months.
As a provider, you need to verify if a member has a restriction
before providing services.
If you provide services to a member enrolled in this program and
you are not the assigned physician, pharmacy or hospital claims
payment may be impacted.
Eligible services provided to a member in the access management
program will be reimbursed only when one of the following
criteria is met:
The service is provided by the member’s assigned provider.
The service is of a provider type or type of service that is not
listed as needing access management.
This includes durable medical equipment (DME), home care,
ambulance services, mental health or chemical health services.
Access management specialists will refer suspect cases to the
special investigation unit (SIU) as needed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-27