Blue Choice HMO Benefits - Harford County Public Schools

11.4 Conditions for a Referral to a Non-Contracting Specialist or Non-Contracting
Nonphysician Specialist.
A Specialist is a physician who is certified or trained in a specified field of medicine.
A Nonphysician Specialist means a Health Care Provider who:
1. is not a physician;
2. is licensed or certified under the Health Occupations Article of the Annotated
Code of Maryland or the applicable licensing laws of any State or the District of
Columbia; and
3. is certified or trained to treat or provide Covered Services for a specified
condition or disease in a manner that is within the scope of the license or
certification of the Health Care Provider.
A Member may request a referral to a Specialist or Nonphysician Specialist who is not a
Contracting Physician or Contracting Provider if:
1. The Member is diagnosed with a condition or disease that requires specialized medical
care; and
a. CareFirst BlueChoice does not contract with a Specialist or Nonphysician
Specialist with the professional training and expertise to treat or provide Covered
Services for the condition or disease; or
b. CareFirst BlueChoice cannot provide reasonable access to a Specialist or
Nonphysician Specialist with the professional training and expertise to treat or provide
Covered Services for the condition or disease without unreasonable delay or travel.
2. The non-contracting Specialist or Nonphysician Specialist will be reimbursement the
same as would be provided to a specialist who is a Contracting Physician or Contracting
Provider. The Member may be subject to balance billing.
A decision by CareFirst BlueChoice not to provide access to or coverage of treatment by a
Specialist in accordance with this section constitutes an Adverse Benefit Determination as
defined in the Program Description, if the decision is based on a finding that the proposed service
is not Medically Necessary, appropriate, or efficient.
11.5 Continuing Care with Terminated Providers.
A. When a Contracting Provider terminates their agreement with CareFirst BlueChoice, for
any reason except for cause, benefits will be provided for continuing care rendered by the
terminated provider as described in this Section. CareFirst BlueChoice will send a notice
to the Member that the Contracting Provider is no longer available.
B. The Member may, upon request, continue to receive Covered Services from his/her PCP
for up to 90 days after the date of the notice of the PCP’s termination from CareFirst
BlueChoice’s provider panel, if termination was for reasons unrelated to fraud, patient
abuse, incompetency, or loss of licensure status. In addition, a Member may continue
treatment with a terminated provider if:
1. A Member was in an active course of treatment with the terminated Contracting
Provider prior to the date the Member was notified. The Member needs to
request, from CareFirst BlueChoice, to continue receiving care from the
terminated Contracting Provider. Benefits will be provided for a period of 90
days from the date the Member is notified by CareFirst BlueChoice that the
terminated Contracting Provider is no longer available.
MD/GHMSI/CFMI BC (R. 10/10)
CareFirst BlueChoice
Harford County Public Schools 39 7/1/2011