Implementation Guide: Bluecard For Public Exchange Products: VERSION 1.0 - January 10, 2013

VERSION 1.
0 January 10, 2013
National Programs
IMPLEMENTATION GUIDE: BLUECARD FOR PUBLIC EXCHANGE PRODUCTS Version 1.0
NOTE: This guide published on January 10, 2013 will assist Plans in preparing to deliver their products offered on state-run, federal-partnership, or federallyfacilitated Exchanges within the BlueCard Program.
VERSION 1.0 January 10, 2013

Contents
CHAPTER 1: OVERVIEW ................................................................................................................................. 5 BlueCard for Public Exchange Products .................................................................................................... 5 BCBSA Contacts ......................................................................................................................................... 5 BlueCard for Public Exchange Products Contacts ..................................................................................... 6 BlueCard for Public Exchange Products Implementation Conference Calls ............................................. 7 Definitions ................................................................................................................................................. 7 2014 BlueCard for Exchanges Plan Participation ...................................................................................... 8 Composition of the National Exchange Qualified PPO Network ............................................................ 10 Naming the Qualified PPO Network ....................................................................................................... 11 CHAPTER 2: OPERATIONS ........................................................................................................................... 12 Create an Internal Team for the Implementation of BlueCard for Exchanges and Identify a Primary Implementation Contact ......................................................................................................................... 12 Complete any Provider Contracting Changes for BlueCard for Public Exchanges .................................. 13 Designate an Exchange Marketing Material Contact ............................................................................. 15 Designate an Exchange Compliance Contact .......................................................................................... 15 Make Decisions on Exchange Products and Network Access ................................................................. 16 Complete Set-up for Print-On-Demand Directories ............................................................................... 17 Notify BCBSA of any Special Exchange Marketing Material Requirements Related to Provider Directories .................................................................................................. Error! Bookmark not defined. Notify BCBSA of any Inter-Plan Exchange Compliance Impacts ................ Error! Bookmark not defined. Requisition of Product/Network IDs & Submission of Provider Data for Networks Accessed by Exchange PPO members ......................................................................................................................... 22 Begin Making Local System Changes for Par/Host Pricing and Control/Home Plan Benefit Application ................................................................................................................................................................ 26 Apply for Certification of a Product as a Qualified Health Plan (QHP) by the State-Run, FederalPartnership, or Federally-Facilitated Exchange ...................................................................................... 27 Complete Survey to Determine Inclusion in the National Exchange Qualified PPO Network................ 27 Submit Data for Physician Quality Measurement (PQM) and Blue Physician Recognition (BPR) .......... 28 Submit Pricing Methods and Rule Combinations for Exchange Claims .................................................. 28 Set-up Plan Profiles ................................................................................................................................. 30 Prepare New Disclosure Language ......................................................................................................... 30

Alpha Prefix Set-up for National Doctor and Hospital Finder/ BlueCard Access Call Center/ Mobile App ................................................................................................................................................................ 31 Provider Education.................................................................................................................................. 33 Member Education ................................................................................................................................. 34 Internal Customer Service Staff Training ................................................................................................ 34 Produce ID Cards for Exchange Members with the Correct Suitcase Logo Indicating Out-of-Area Network Access ....................................................................................................................................... 34 Submit Cost Data for Exchange Networks to the National Consumer Cost Tool (NCCT) ....................... 35 Complete Global Certification for ITS Release 13.5 ................................................................................ 35 Prepare to Send Exchange PPO Network Alerts ..................................................................................... 36 CHAPTER 3: SYSTEMS .................................................................................................................................. 37 Par/Host Plan Pricing Scenarios .............................................................................................................. 38 Control/Home Plan Benefit Scenarios .................................................................................................... 65 Plan Profiles ............................................................................................................................................ 84 CHAPTER 4: ADDITIONAL INFORMATION ................................................................................................... 93 Inter-Plan Fees ........................................................................................................................................ 93 Licensee Desk Level Audits (LDLA) .......................................................................................................... 94 Appeals and Grievances .......................................................................................................................... 94 Network Reporting Services ................................................................................................................... 95 Inter-Plan Programs Performance/ Scorecard........................................................................................ 95 Claims Handling for Claims Received During the Exchange Individual Grace Period ............................. 96 Consumer Transparency Reporting for Exchange Business.................................................................... 97 Risk Adjustment ...................................................................................................................................... 99 BlueCard Worldwide ............................................................................................................................. 99 Blue Distinction ....................................................................................................................................... 99 Pre-Certification and Eligibility Line ........................................................................................................ 99 SHOP Exchange Enrollment .................................................................................................................. 100 CHAPTER 5: Exhibits .................................................................................................................................. 101 Exhibit 1: Plan Implementation Checklist ............................................................................................ 101 Exhibit 2: Reporting Implementation Progress in BlueServ .................................................................. 105 EXHIBIT 3: Disclosure Language ............................................................................................................ 108 EXHIBIT 4: Provider Education Material ............................................................................................... 111

Exhibit 5: Federal Legislation and Regulation References ................................................................... 113 Exhibit 6: Inter-Plan Policy References ................................................................................................ 114 Exhibit 7: Sample Q2 2013 Survey Questions to Determine Inclusion in a Defined, National, Predeployed Exchange Qualified PPO Network ......................................................................................... 115 Revision Log .............................................................................................................................................. 118
VERSION 1.0 January 10, 2013 CHAPTER 1: OVERVIEW

BlueCard for Public Exchange Products
The Patient Protection and Affordable Care Act (PPACA), passed in March 2010, expands access to health insurance through the establishment of American Health Benefits Exchanges. States may establish exchanges to facilitate the purchase of Qualified Health Plans (QHPs) for eligible individuals and small employer groups. State Exchanges must be approved or conditionally approved by HHS by January 1, 2013. If a state does not create this online health insurance marketplace by January 1, 2013, a federally-facilitated Exchange will be created for the state. In order to offer products on Exchanges, Blue Plans must meet Exchange Qualified Health Plan certification requirements. For example, Plans must offer products at the Silver and Gold actuarial coverage levels. Additionally, as part of the QHP certification process, networks accessed by Exchange members will need to meet Exchange network standards. Based on survey data, many Blue Plans will offer products on state or federally-facilitated Exchanges. The BlueCard for Public Exchange Products initiative will ensure Plans have flexible out-of-area network options for their individual and small group public Exchange members. The project will also ensure the Inter-Plan Program policies and systems are set-up to allow Plans to comply with any special public Exchange requirements. This guide will assist your Plan in understanding key steps for Exchange product delivery through National Programs. Plans must adhere to the requirements as specified in the IPP Policies and Provisions. Note: This guide does not apply to the Blue Private Exchange initiative. Information on the Blue Private Exchange initiative can be found at the following link on BlueWeb: http://bluewebportal.bcbs.com/landingpagelevel3/703250?docId=24753
BCBSA Contacts
Please feel free to contact the appropriate Association staff below with questions/comments related to BlueCard for Public Exchange Products: Area of Expertise National Delivery Government Program Delivery Government Program Delivery Business Applications Contact Name Dave Strachan Karin Johnson Tracy Carruthers Chris Phone Number 312.297.6156 312.297.6452 312.297.6311 312.297.6387 Email Address David.Strachan@bcbsa.com Karin.Johnson@bcbsa.com Teresa.Carruthers@bcbsa.com Christopher.Hallauer@bcbsa.com 5

Area of Expertise Systems Business Analyst Directories Provider Data Service Unit (PDSU) Provider Directories: BlueCard Access Call Center, National Doctor and Hospital Finder, Print-On-Demand Directories Network Reporting Services Network Alerts Provider, Member, Staff Education Cathy Reice Appeals and Grievances Licensee Desk Level Audits IPP Performance/ Scorecard Disclosure Language IPP Fees Transparency Reporting Provider Networks Member ID Cards 312.297.6619 Contact Name Hallauer Lisa Adams John Reid Sue Robertson Phone Number 312.297.5893 312.297.5967 Email Address Lisa.Adams@bcbsa.com John.Reid@bcbsa.com
312.297.6639
Sue.Robertson@bcbsa.com
Bill Witt Angela Harris Nancy Williams
312.297.6585
william.witt@bcbsa.com
312.297.6854 312.297.6849
Angela.harris@bcbsa.com Nancy.Williams@bcbsa.com
Catherine.Reice@bcbsa.com
Derek Morris Brenda Muehlbauer Andrew Korsak Ken Matuszak Chris Oh Chad Jacobs
312.297.5874 312.297.6921 312.297.6503 312.297.5675 312.297.6335 312.297.6640
Derek.Morris@bcbsa.com Brenda.Muehlbauer@bcbsa.com Andrew.Korsak@bcbsa.com Ken.Matuszak@bcbsa.com Christopher.Oh@bcbsa.com Chad.Jacobs@bcbsa.com
BlueCard for Public Exchange Products Contacts

Communications about BlueCard for Public Exchange Products will be sent to the BlueCard for Exchanges Primary Implementation Contacts, Exchange Internal Contact list, Marketing Material Contacts, and Compliance Contacts, as applicable. Please see Chapter 2 on Operations 6

for more detail on determining these contacts within your Plan and ensuring that they are added to the appropriate distribution lists. Plan contacts are posted on BlueWeb at the following link: http://bluewebportal.bcbs.com/landingpagelevel3/703150?docId=24895#0.1
BlueCard for Public Exchange Products Implementation Conference Calls

Throughout the second half of 2012 BCBSA held monthly all-Plan implementation conference calls. Additional calls will be held in 2013 to provide Plans with updates and reminders. All Blue Plans are welcome to participate in the calls. The dates, dial-in information, and materials for these calls will be posted on BlueWeb at the following link: http://bluewebportal.bcbs.com/landingpagelevel3/703150?docId=24895 Memos on BlueCard for Public Exchange Products Conference Calls will be sent to Plans BlueCard Executives, National Account Executives, ITS Coordinators, and BlueCard for Exchanges Primary Contacts (see Chapter 2 for more information on the BlueCard for Exchanges Primary Implementation Contact).
Definitions
Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name Affordable Care Act is used to refer to the final, amended version of the law. Custom Network: A Par/Host Licensees provider network, other than a designated BlueCard provider network, required to be made available to a Control/Home Licensee. Essential Community Providers: Health care providers that serve predominately low-income, high-risk, special needs and medically-underserved individuals. The Department of Health and Human Services (HHS) proposes to define essential community providers as including only those groups suggested in the ACA, namely those named in section 340B(a)(4) of the Public Health Service Act and in section 197(c)(1)(D)(i)(IV) of the Social Security Act. Exchange: For purposes of this document, the term Exchange refers to the public exchange as established pursuant to the Affordable Care Act (ACA): A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Exchanges will offer a choice of health plans that meet certain benefits and cost standards. The ACA allows for each state the opportunity to establish a State-based Exchange. Recognizing that not all States may elect to establish a State-based Exchange, the ACA directs the Secretary of HHS to establish and operate a Federally-facilitated Exchange in any State that does not do so, or will not have an operable Exchange for the 2014 coverage year, as determined by January 1, 2013. 7

Exchange PPO Designated Networks: All of the networks (non-overlapping and overlapping) selected to be included in the National Exchange Qualified PPO Network will be referred to as Exchange Designated networks. Exchange PPO Non-designated Networks: An Exchange PPO network not included in the National Exchange Qualified PPO Network. National Exchange Qualified PPO Network: The most appropriate Exchange network(s) chosen for use by Individual and SHOP Exchange members. All of the networks (non-overlapping and overlapping) selected to be included in the Blue National Exchange Qualified PPO Network will be referred to as Exchange Designated networks. In portions of the country where Exchange Designated networks do not exist, BlueCard PPO networks will be used to fill in the gaps. Small Business Health Options Program (SHOP): Allows employers to choose the level of coverage and offer choices among health insurance plans. State-run Exchanges are scheduled to become available by January 2014, with the federal government stepping in to run Exchanges for states that are not ready. For 2014 and 2015, states can decide whether to include businesses with 100 or fewer or 50 or fewer employees in their Exchange. In 2016, all businesses with 100 or fewer employees must be able to purchase insurance through these Exchanges. The Exchanges have the option of including employees with more than 100 employees beginning in 2017. Qualified PPO Custom Network: A Par/Host Licensees provider network, other than existing BlueCard PPO networksand custom networks (e.g. Altnets and Blue Precision networks) accessed by Exchange PPO members. Qualified Health Plan (QHP): Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.
2014 BlueCard for Exchanges Plan Participation

Thirty-eight Blue Plans responded to an all-Plan Exchange survey issued in Fall 2012. Thirtythree of the 38 Plans intend to offer products on Individual Exchanges. Twenty-seven of the 38 Plans intend to offer products on SHOP Exchanges. Below are high level statistics from the Fall 2012 Exchange survey. BCBSA will continue to track Plan Exchange participation. Control/Home Plan Participation Exchange Participation (as of Q4 2012) 8

Individual Exchange Participation: 33 of 38 Plans intend to offer products on the Individual Exchange. 5 of 38 Plans, or 13%, have not decided whether they will offer products on the Individual Exchange. SHOP Exchange Participation: 27 of 38 Plans intend to offer products on the SHOP Exchange. 7 of 38 Plans do not intend to offer a SHOP product. 4 of 38 Plans, or 11%, have not decided whether they will offer products on the SHOP Exchange. Exchange PPO Products (as of Q4 2012) Individual Exchange PPO Product Offerings: 31 of 33 Plans that intend to offer an Individual Exchange product will offer a PPO and/or EPO product. 2 of 33 Plans that intend to offer an Individual Exchange PPO product will not offer a PPO and/or EPO product. SHOP Exchange PPO Product Offerings: 25 of 27 Plans that intend to offer a SHOP Exchange product will offer a PPO and/or EPO product. 2 of 27 Plans that intend to offer a SHOP Exchange product will not offer a PPO and/or EPO product. Par/Host Plan Participation All Blue Plans will be Par/Host Plans for out-of-area Exchange business. Thirty-two Plans covering 47 states will use Exchange Qualified PPO Networks. Par/Host Plan Exchange Qualified PPO Networks (as of Q4 2012): 32 Plans intend to have an Exchange Qualified PPO network across 47 states (number of states includes D.C., Puerto Rico, and US Virgin Islands). 5 Plans in 5 states are unsure if they will have an Exchange Qualified PPO network. 1 Plan in one state does not intend to have an Exchange Qualified PPO network. Types of Exchange Qualified PPO Networks for Local Members (as of Q4 2012): 30 Plans in 45 states will use BlueCard PPO networks. 15 Plans in 30 states will use new Qualified PPO networks. 3 Plans in 3 states will use Altnet custom networks. 1 Plan in 1 state will use a Blue Precision custom network.

Composition of the National Exchange Qualified PPO Network
Similar to what is done for the BlueCard PPO network, in Q3 2013 BCBSA will select the most appropriate Exchange Qualified PPO Network(s) for each Plan for inclusion in a defined, predeployed National Exchange Qualified PPO Network. All non-overlapping Exchange PPO Networks within Plan service areas will be included in the National Exchange Qualified PPO Network. Where a Plan has multiple, overlapping Exchange PPO Networks, BCBSA will utilize network evaluation methodology to choose which Exchange PPO Network to include in the defined national set. o Criteria will be based on the combined factors approved by the Inter-Plan Programs Committee (IPPC)- an equal weighting of: Provider Access (33.3%); Weighted Savings (33.3%); and Geographic Distribution (33.3%) o A detailed description of the methodology can be found in Chapter 7 of the InterPlans Program Manual. NOTE: The entire network will be included in the evaluation. BCBSA will employ BlueCard PPO networks for fill in gaps where Exchange Qualified PPO Networks are not available.
By January 1, 2013, Plans offering Exchange PPO (or EPO) products will have requested new product and network IDs (See Chapter 2 for detail). Additionally, Plans offering an Exchange PPO (or EPO) product will have notified BCBSA. The information on which Plans will have Exchange PPO networks will allow BCBSA to begin determining the composition of the National Exchange Qualified PPO Network. The following types of networks could be included in the National Exchange Qualified PPO Network: BlueCard PPO networks New Exchange Qualified PPO networks Other networks (excluding BluePrecision) In early Q2 2013, BCBSA will issue an all-Plan survey requesting information on Plans networks accessed by Exchange PPO or EPO members. Plans will be asked for information related to: Inpatient, outpatient, and professional discounts for each network. Number of counties covered by each network. Number of counties in Plans licensed service area. Please see Exhibit 7 for sample survey questions. By June 1, 2013, BCBSA will have received all Exchange PPO provider data files from Plans for networks effective January 1, 2014. BCBSA will use the survey information and provider data received to determine which Exchange Qualified PPO Networks will be included in the new, pre-deployed National Exchange Qualified PPO Network. 10

Upon receipt of information on each Plans network(s) accessed by Exchange PPO members (through a survey issued in early 2013) and upon receipt of any new Exchange Qualified PPO provider data BCBSA will provide information to each Plan on which network(s) will be included in the new, National Exchange Qualified PPO network. Example of Selection of Qualified PPO Networks for a Plan with Overlapping Exchange PPO networks: Plan A has two overlapping Exchange PPO networks within their Plan service area and one nonoverlapping Exchange PPO network. Network 1 covers three counties, has good weighted savings, and good provider access and overlaps with Network 2 Network 2 covers five counties, and has the same weighted savings and provider access as Network 1 Network 3 covers 4 counties and does not overlap with Network 1 or Network 2
Based on the network evaluation criteria, Networks 2 and Network 3 would be the networks that would be selected to be included in the National Exchange Qualified PPO network.
Naming the National Exchange Qualified PPO Network

BCBSA is currently working on developing a name for the National Exchange Qualified PPO network. The name for the new National Exchange Qualified PPO network will be used to communicate with providers and Plans.
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VERSION 1.0 January 10, 2013 CHAPTER 2: OPERATIONS

The implementation of BlueCard for Public Exchange Products will involve operational changes for both Control/Home and Par/Host Plans. The key operational activities for BlueCard for Public Exchange Products are outlined in chronological order in the steps listed below. The dates included for each step are suggested timeframes for Plans to follow for the implementation of BlueCard for Public Exchange Products for 2012 through 2014. Each implementation step is categorized by Plan Exchange Participation Level. Plans should complete each implementation step applicable to their Plan Exchange Participation Level: BlueCard For Public Exchange Products- PPO or EPO: These steps apply to only Blue Plans that intend to offer a PPO and/or EPO product. Plans who intend to offer PPO and/or EPO products on Exchange should complete these steps (even if offering other products). BlueCard For Public Exchange Products- Not Offering PPO or EPO: These steps apply to Blue Plans that are not offering a PPO or EPO product on Exchanges, but offering products other than PPO or EPO. BlueCard For Public Exchange Products- Not Offering Any Public Exchange Products: These steps apply to only Blue Plans that do not intend to offer products on Exchanges.
The Plan Implementation Checklist located in Exhibit 1 may also be helpful in the implementation of BlueCard for Public Exchange Products.
Create an Internal Team for the Implementation of BlueCard for Exchanges and Identify a Primary Implementation Contact
Recommended Plan Completion Date: August 1, 2012 Plan Exchange Participation Level: All Plans must complete this step. Plans will need to create an internal team within their Plan for the implementation of BlueCard for Exchanges. Plans may wish to consider including individuals from the following areas: BlueCard Executive National Account Executive Individual Business Product Development Provider Network Administration Claims Adjudication Customer Service Claims Pricing ITS Operations Provider Directories 12

Health Care Reform Policy Experts Project Manager IT NASCO Finance Membership and Billing BlueExchange BlueSquared
Plans should also identify a Primary Implementation Contact for BlueCard for Public Exchange Products. The Primary Implementation Contact is responsible for tracking Plan implementation progress. Plans should make sure each staff member that is part of the internal BlueCard for Exchanges implementation team and the Primary Implementation Contact have access to BlueWeb and sign up staff as needed by clicking on the following link: https://blueweb.bcbs.com/directories/NewUserRegistration After BlueWeb access has been verified, the designated contacts should email BlueCardforExchanges@bcbsa.com to be added to the appropriate list.
Complete any Provider Contracting Changes for BlueCard for Public Exchanges
Recommended Plan Completion Date: March 15, 2012 - August 1, 2013 Plan Exchange Participation Level: PPO or EPO Plans should begin reviewing their provider contract language to ensure that, effective January 1, 2014, provider contracts for networks accessed by Exchange PPO (or EPO) members contain language to support the following: Guaranteed provider access to all Individual and SHOP Exchange PPO and EPO members. Provider reimbursement at the Par/Host Plans contracted PPO rate for covered services. Guaranteed provider access for off- Exchange national account members, if the Plans off-Exchange national account members have access (i.e. - marketed or made available to local members of another national account) to the network.
National Exchange Qualified PPO Network (Exchange PPO Designated Networks) BCBSA will select the most appropriate Exchange network(s) for use by Individual and SHOP Exchange members, for inclusion in a defined, pre-deployed National Exchange Qualified PPO Network: All non-overlapping networks accessed by Exchange PPO members within Plan service areas would be included in the defined set of Exchange Networks. 13

If a Par/Host Plan has multiple networks supporting Exchange PPO (or EPO) products sharing the same geographic area, the network providing the best combination of factors outlined in the network analysis criteria approved by IPPC and published in the Inter-Plan Programs Manual will be selected to be included in the new National Exchange Qualified PPO Network.
Networks (non-overlapping and overlapping) selected for inclusion in the new National Exchange Qualified PPO Network will be referred to as Exchange PPO designated networks. In portions of the country where exchange PPO designated networks do not exist, BlueCard PPO networks will be used to fill in the gaps. Exchange PPO Non-Designated Networks Networks supporting Exchange PPO (or EPO) products excluded from the National Exchange Qualified PPO Network may be accessed by Exchange members through negotiated arrangements. Payment Innovations Licensees making provider care delivery reimbursement arrangements available to Exchange PPO and EPO members should adhere to the criteria established in Inter-Plan Policy 3.14, Provider Care Delivery Reimbursement Arrangements: Additional information on payment innovations can be found on BlueWeb at: http://bluewebportal.bcbs.com/landingpagelevel3/703300?docId=22623 Please contact Brenda Bechtold (Brenda.Bechtold@bcbsa.com) with questions on payment innovations. Contiguous Counties In developing networks, Plans should follow Brand regulations related to contiguous counties situations. This information can be found on BlueWeb at: http://blueweb.bcbs.com/blueweb/leaf?catid=203200;docId=12648 Contiguous counties claims filing scenarios can be found in Chapter 6 of the Inter-Plans Program Manual. Remote Provider Contracting Rules Plans should continue to follow Brand regulations when contracting with remote providers for Public Exchange business. For more information see the Inter-Plan Programs Policies definition for Remote Provider and Inter-Plan Programs Policy 2.01, Licensee Participation, both available via the IPP Policies and Provisions section of the Inter-Plan Programs Manual page on BlueWeb. 14

Designate an Exchange Marketing Material Contact
Recommended completion date: August 1, 2012 Plan Exchange Participation Level: PPO or EPO Plans should designate an Exchange Marketing Material contact within their Plan by August 1, 2012. The Marketing Material contact will be responsible for tracking Exchange marketing requirements related to provider locator programs (web-based directories, printed directories, and call centers) and should notify BCBSA of any special requirements affecting BCBSA provider locator tools (National Doctor and Hospital Finder website, Print-on-Demand Provider Directories, BlueCard Access Call Center) by November 1, 2012 by sending an email to ThirdPartyServices@bcbsa.com Examples of special marketing requirements for provider directories may include: Identification of Essential Community Providers Special formatting requirements: font type, sequence of providers listed, etc. Special verbiage for printed directories Plans should make sure that Exchange Marketing Material contacts have access to BlueWeb. Contacts that do not have access to BlueWeb should click on the following link for new user registration instructions: https://blueweb.bcbs.com/directories/NewUserRegistration. After BlueWeb access has been verified, the designated contacts should email BlueCardforExchanges@bcbsa.com to be added to the appropriate list.
Designate an Exchange Compliance Contact

Recommended completion date: August 1, 2012 Plan Exchange Participation Level: All Plans must complete this step. BCBSA will be working with Plans in the first and second quarters of 2013 to ensure that InterPlan Policies and Processing Standards allow for Blue Plans to meet state or federal Exchange requirements. Plans should designate one or more Exchange Compliance contacts by August 1, 2012. The Exchange Compliance Contact will be responsible for understanding Exchange requirements, identifying inter-Plan impacts, and notifying BCBSA of any impacts, so that any necessary revisions to Policy can be made. The contact should be knowledgeable about state and federal Exchange requirements as well as IPP Policies and Processing Standards. Plans should make sure that Exchange Compliance contacts have access to BlueWeb. Contacts that do not have access to BlueWeb should click on the following link for new user registration instructions: https://blueweb.bcbs.com/directories/NewUserRegistration.
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After BlueWeb access has been verified, the designated contacts should email BlueCardforExchanges@bcbsa.com to be added to the appropriate list.
Make Preliminary Decisions on Exchange Products and Network Access

Recommended Plan Completion Date: September 1, 2012 Plan Exchange Participation Level: All Plans must complete this step. By September 1, 2012, Plans should have prepared for a survey by preliminarily determining, based on information available, the Exchange products they intend to offer and the networks in their service area that will be accessed by Exchange members. The table below includes the outof-area network options for Exchange products. BCBSA issued a survey in late Q3 2012 to determine Plan benefit designs for Exchange products, networks accessed inside Plan service areas, and networks accessed outside of Plan service areas. Results of this survey are posted to BlueWeb on the BlueCard for Public Exchange Products Implementation page.
Individual and SHOP Exchange Product/ Out-of-Area Network Access Options Product Type Out-of-Area Network Access Options Out-of-Area Network Access Descriptions
National Exchange Qualified PPO Network For PPO members with: out-of-area in-network benefits OR no out-of-area benefits (in-network or out-of-network) besides for urgent or emergent care BlueCard PPO Network Standard Networks PPO (or EPO) For PPO members with: out-of-area in-network benefits OR no out-of-area benefits (in-network or out-of-network) besides for urgent or emergent care BlueCard Traditional Network For PPO members with: no out-of-area in-network benefits, but with out-of-area out-ofnetwork benefits (lower level benefits) and benefits for urgent or emergent care
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Product Type Out-of-Area Network Access Options Out-of-Area Network Access Descriptions
Qualified PPO Custom network in custom arrangement service area: Qualified PPO Custom Outside of custom arrangement service area access to either National Exchange Qualified PPO, BlueCard PPO, or BlueCard Traditional network AltNet network in custom arrangement service area: Outside of custom arrangement service area access to either National Exchange Qualified PPO, BlueCard PPO, or BlueCard Traditional network Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area: Outside of custom arrangement service area access to either National Exchange Qualified PPO, BlueCard PPO or BlueCard Traditional network Blue Precision custom network and BlueCard Traditional wrap in the custom arrangement service area: Blue Precision Custom Outside of custom arrangement service area access to either National Exchange Qualified PPO, BlueCard PPO, or BlueCard Traditional network Blue Precision custom network and no wrap in the custom arrangement service area: Outside of custom arrangement service area access to either National Exchange Qualified PPO, BlueCard PPO, or BlueCard Traditional network BlueCard Traditional Network Standard Network
Altnet Custom
Traditional POS HMO
Instructions for Plans That Will Not Have an Exchange Qualified PPO Network
Recommended Completion Date: January 1, 2013 Plan Exchange Participation Level: Not Offering PPO or EPO; Not Offering Any Public Exchange Products This section is intended for Plans that do not intend to offer Exchange PPO (or EPO) products. 17

Plans should notify BCBSA by January 1, 2013 if they will not offer an Exchange PPO (or EPO) product in 2014, and therefore, will not have an Exchange Qualified PPO network. In areas where an Exchange PPO network is not available, BCBSA will employ BlueCard PPO networks to fill in the gaps. The BlueCard program will provide access and favorable discounts for travelers and out-of-area resident members. If a Plan will not offer an Exchange PPO (or EPO) product in 2014, the Plan should send an email to Bluecardforexchanges@bcbsa.com by January 1, 2013.
Notify BCBSA of any Inter-Plan Exchange Compliance Impacts

Recommended completion date: January 1 - May 1, 2013 Plan Exchange Participation Level: All Plans must complete this step. Plans should examine state and federal Exchange requirements to identify potential Inter-Plan impacts related to compliance, so that necessary revisions can be made to Inter-Plan Policies and Processing Standards. Exchange requirements may have Inter-Plan impacts, for example, if one Plan would need to rely on another to meet a requirement. BCBSA has created a schedule to help facilitate the careful review of Inter-Plan Programs Policies and Processing Standards as they relate to Exchange requirements. The review process is scheduled to begin after January 1, 2013, by which time state Exchange requirements will likely have been released. The Compliance contact should notify BCBSA of any state and federal Exchange requirements that may impact Inter-Plan business by May 1, 2013 by sending an email to Bluecardforexchanges@bcbsa.com. To assist you in your efforts, BCBSA will create a feedback form for Plans. The form will be posted to the Implementation of BlueCard For Public Exchange Products BlueWeb page: http://bluewebportal.bcbs.com/landingpagelevel3/703150?docId=24895 by 1/15/13. BCBSA will hold three all-Plan calls to review and discuss potential changes to IPP Policy and Processing Standards.
IPP Policies and Provisions
1.01-3.14 Program Operations, Eligibility and Participation, Finance 4.01-7.04 Administration, Regulatory, ClaimRelated Requirements, Performance 8.01-15.03 National Accounts, Member and Provider Services, Medicare, International, BlueExchange, BlueSquared, Exchanges
IPP Processing Standards

1.01-4.05 Par/Host Licensee Responsibilities: Admin and Claims, Control/Home Licensee Responsibilities: Admin and Claims 5.01-6.11 Par/Host and Control/Home Licensee Responsibilities: Admin and Claims
BCBSA Posts Initial Analysis

1/31/13
Plan Review Deadline

2/14/13
Meeting Date
2/21/13
3/7/13
3/21/13
3/28/13
7.01-10.01 National Accounts, Adjustments, International Claims, Grievances and Appeals
4/11/13
4/25/13
5/2/13
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BCBSA needs to receive information on potential Inter-Plan impacts by May 1, 2013, so any changes to IP Policies and Processing Standards can be taken through BCBSA governance in Q3 2013.
Notify BCBSA of any Special Exchange Marketing Material Requirements Related to Provider Directories
Recommended completion date: February 1, 2013 Plan Exchange Participation Level: PPO or EPO The Exchange Marketing Material contact is responsible for tracking Exchange marketing requirements related to provider directories (web-based directories, paper directories, and call centers). The Marketing Material contact should notify BCBSA of any special marketing requirements that may affect BCBSA provider locator tools (Blue National Doctor and Hospital Finder website, Print-on-Demand Provider Directories, BlueCard Access Call Center) by February 1, 2013 by sending an email to ThirdParyServices@bcbsa.com. Examples of special marketing requirements for Exchange provider directories may include: Identification of Essential Community Providers Special formatting requirements: font type, sequence of providers listed, etc. Special verbiage for printed directories BCBSA needs information on special marketing requirements for directories by February 1, 2013, so that enhancements to directories can be implemented prior to Exchange enrollment in October 2013.
Complete Set-up for Print-On-Demand Directories

Recommended completion date: February 1, 2013 Plan Exchange Participation Level: PPO or EPO Overview: Print-on-Demand Set-up Steps Control/Home Plans will be able to order printed or emailed directories for Exchange PPO members, once they have been set-up to access the National Exchange Qualified PPO Network, the BlueCard PPO Network or Qualified PPO Custom Networks, through the Print-on-Demand program. To set up Print-On-Demand directories for Exchange business, Plans will need to send an email to ThirdPartyServices@bcbsa.com by February 1, 2013. Include the subject line Exchange POD Directory Set-up for [Plan Name] along with the following information: Blue Plan Name (Example: BlueCross and BlueShield of Florida) Any special instructions for the set-up of Geographic source directories Any special marketing requirements related to paper directories
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Beginning in September 2013, Blue Plans will be able to order 2014 Exchange Directories through the Print-on-Demand system. The following directory types will be available: Quick Provider Directories (QPD), Geographic Provider Directories (GPD), and Custom Provider Directories (CPD). Geographic Source Directories To allow for paper directories to be created containing providers in the National Exchange Qualified PPO network, Geographic source directories will be created for: Each Blue Plans service area(s). Each Qualified PPO custom network. For states in which multiple Blue Plans are licensed, a statewide geographic source directory will also be created. Plans should send an email to ThirdPartyServices@bcbsa.com by February 1, 2013 if they would like the geographic source directories for their Plans service area broken into smaller directories (smaller than the Plans service area in a state). Ordering Print-on-Demand Directories Plans that intend to order Print-on-Demand paper directories should: Determine the staff at their Plan who regularly requests Print-on-Demand Paper Directories. Contact the Help Desk at ThirdPartyServices@bcbsa.com to obtain a user name and password if additional staff needs access to order Print-on-Demand Directories. Ordering Print-on-Demand Directories in Bulk If your Plan will be ordering Print-on-Demand Directories in bulk (more than a thousand directories at a time), please send the following information to ThirdPartyServices@bcbsa.com with the subject line Bulk Print-on-Demand Orders: Approximate number of directories to be requested for your Plan Approximate date when your Plan will be ordering their Exchange Directories for 2013. These steps will ensure that vendor resources are ready for bulk orders. Print-on-Demand Directory Costs Source Directory Creation Costs One source directory will be created for each Blue Plan service area, unless the Plan requests the source directories to be broken down further. Additionally, a statewide directory will be created for all states in which multiple Blue Plans are licensed. Source directories will also be created for each Qualified PPO custom network. Each Blue Plan will be charged through Grand Billing for the source directories created containing their Qualified PPO providers. Charges for the creation of source directories will vary depending on the number of source directories created at 20

one time. The grid below displays how costs per source directory are reduced when more than one is ordered. Source Directory Cost Breakdown:
Source 1 2 3 4 5 6 7 8 9 10 Total Price 1,650 2,400 3,150 3,900 4,650 5,400 6,150 6,900 7,650 8,400 Total Price Per Book 1,650 1,200 1,050 975 930 900 879 863 850 840
$ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $
Please contact Sue Robertson (Sue.Robertson@bcbsa.com) with questions related to the costs to produce source directories. Print-on-Demand Functionality Enhancements Additionally, there will be enhancements to the system to allow Plans to order directories containing providers in the Qualified PPO networks and Qualified PPO custom networks. These enhancements will be charged across all Plans through Grand Billing. Special Marketing Material Requirement Enhancement Costs Federal Exchange Marketing Material Requirements: The final rule on Exchanges requires provider directories to indicate which providers are not accepting new patients. Currently Print-on-Demand directories do not include an indicator for those providers not accepting new patients. An enhancement to Print-onDemand directory formatting will be made in September 2013 to include an indicator in paper directories for BlueCard PPO, Altnets, and Qualified PPO networks. The enhancements related to federal marketing requirements will be charged to Plans through Grand Billing. State or Federally-facilitated Exchange Marketing Material Requirements: State and federally-facilitated Exchanges may have special marketing materials requirements, such as enhancements to Print-On-Demand directories. Any enhancements related to state-specific marketing requirements will be charged to the specific Plan requesting the change.
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Requisition of Product/Network IDs & Submission of Provider Data for Networks Accessed by Exchange PPO members
Step 1: Request New Exchange PPO Network and Product ID Codes Recommended completion date: by January 1, 2013 Plan Exchange Participation Level: PPO or EPO Step 2: Submit Participating Exchange PPO Provider Data to BCBSA Recommended completion date: January 1, 2013 June 1, 2013 Plan Exchange Participation Level: PPO or EPO Overview Requesting New Exchange PPO Network and Product ID Codes Plans will need to request new network and product ID codes to support new Exchange PPO (or EPO) products, in accordance with Inter-Plan Policy 15.01, Public Exchange PPO Provider Networks. BCBSA understands Plans may still be in the process of obtaining approval of Exchange networks and products by their local exchange and Department of Insurance offices during January 2013- June 2013. However, Plans should request new Exchange PPO network and product ID codes as early as January 1, 2013. Submission of Participating Exchange PPO Provider Data to BCBSA Plans will need to submit participating provider data to BCBSA for networks supporting Exchange PPO products by June 1, 2013 in accordance with Inter-Plan Policy 15.01, Public Exchange PPO Provider Networks. Although Plans may continue to develop Exchange PPO networks throughout 2013, they should submit their initial Exchange PPO provider data to BCBSA as early as January 1, 2013. Blue Licensee Exchange PPO Networks Plans may create new Exchange PPO provider networks and/or use their existing BlueCard PPO or custom network as their Exchange Qualified PPO networks. Additionally, some Plans may have more than one network accessed by Exchange PPO (or EPO) members. There are different implementation steps Par/Host Plans should complete for the following networks: New Exchange Qualified PPO Networks. Existing BlueCard PPO Networks or custom networks accessed by Exchange PPO members. Plans that will not have an Exchange PPO network. For new Exchange PPO networks, Plans should request and obtain new network and product IDs. For BlueCard PPO networks and Custom Networks that will be accessed by Exchange PPO members, Plans only need to request and obtain a new product ID. Plans that will not have an 22

Exchange Qualified PPO network in 2014 will need to notify BCBSA. See appropriate sections below for detailed implementation steps for your Plan. Please contact Debra Riebling (Debra.Riebling@bcbsa.com) with questions related to requesting product and network IDs and submitting provider data files. Instructions for Par/Host Plans with New Exchange Qualified PPO Network(s) This section is intended for Plans implementing new networks or utilizing existing local networks that are not being submitted to BCBSA on a weekly basis via the ITS Provider Data Format (PDF). Plans that will be implementing a new Exchange PPO network to be accessed by Exchange PPO (or EPO) members that is different from their current BlueCard PPO network or an existing custom network should request a new network and product ID code as early as January 1, 2013. For Plans offering more than one Exchange product, multiple product ids to be associated to (possibly new) network id(s) may need to be requested. A product is defined by the providers included and the contracted rates. If the providers differ between products, then the products are required to be associated to separate (possibly new) networks. If a single network of providers supports multiple products with differing contracted rates, then separate product IDs are required to be associated to the single network. Plans should notify the Association when a new network is being developed and scheduled for submission by completing the following steps: Send an email request to pd.requests@bcbsa.com to obtain new network and product IDs. Copy your Plans Provider Data Representative at BCBSA on this email. In the email, include the name of the new network, the type of product (Exchange PPO (or EPO) and the planned implementation schedule for the network. The BCBSA Provider Data Representative will work internally to ensure all systems are properly set up to recognize and process the Plans new network. Within 4 weeks, the Plan will receive a notice indicating the new network ID and product ID that have been assigned, and confirming the Plan Code and the product name.
Exchange Qualified PPO Network provider data must be submitted by June 1, 2013. For full instructions on Implementing a New Network, follow the link below to the Provider Data Plan User Guide, page 1.1: http://bluewebportal.bcbs.com/bluecard/attachments/IPP_ipo_userguide_pdfprocess_chapterone. pdf Steps for scheduling and sending a test Provider Data Format (PDF) file and instructions on how to schedule and send a PDF new network full file are included in the Provider Data Plan Users Guide. Federal Exchange Requirements for Provider Directories
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Federal regulations require all QHP issuers to identify providers not accepting new patients in their provider directories. Par/Host Plans should already be submitting accurate provider data to BCBSA with information on whether the provider is or is not accepting new patients on a weekly basis. Plans should verify they are accurately populating data field P140 on the PDF. Plans should ensure that data field P140 (currently required for individuals and groups) is populated with the 02, 07, or 08 value on the 46B record on the PDF for each provider that is not accepting new patients. Plans should not populate data field P140 with 03 (Inactive) for PPO providers. P140 Value 01 02 03* 04* 05* 06* 07 08 Value Description
Open to New Enrollment Closed to New Enrollment Inactive Hold for Investigation Hold for Additional Information Duplicate PCP Open to Existing Patients Only Open to Existing Patients and Family Members of Existing Patients Only
*Values should be used exclusively for PCPs accessed for Managed Care products. Instructions for Plans Using Existing BlueCard PPO Networks and/or Custom Networks for Their Exchange PPO (or EPO) Members This section is intended for Plans with networks accessed by Exchange PPO members that are identical to the BlueCard PPO network or Custom Networks. A new product ID should be requested for Plans that intend to use their current BlueCard PPO or Custom network as their Exchange PPO network as early as January 1, 2013. BCBSA will add a new product ID to the existing network ID that will identify both networks for provider directories, one identified as the existing network and one identified as the Exchange PPO network. This process will ensure that both networks, BlueCard PPO (or Custom) and Exchange PPO, are reported and separately displayed but contain identical provider information. Plans should notify the Association when an existing BlueCard PPO or custom network is being offered to Exchange PPO members by completing the following steps:
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Send an email request to pd.requests@bcbsa.com to obtain new network and product IDs. Copy your Plans Provider Data Representative at BCBSA on this email. The email should include the name of the new network, the type of product (Exchange PPO (or EPO)) and the planned implementation schedule for the network. The BCBSA Provider Data Representative will work internally to ensure all systems are properly set up to recognize and process the Plans new network. Within 4 weeks, the Plan will receive a notice indicating the new network ID and product ID that have been assigned, and confirming the Plan Code and the product name.
Please see section above titled Federal Exchange Regulations for Provider Directories for important information on verifying the accuracy of information for providers that are not accepting new patients in provider data. Plans should verify that they are accurately populating data field P140 on the PDF. Instructions for Plans That Will Not Have an Exchange Qualified PPO Network This section is intended for Plans that do not intend to offer Exchange PPO (or EPO) products. Plans should notify BCBSA by January 1, 2013 if they will not offer an Exchange PPO (or EPO) product in 2014, and therefore, will not have an Exchange Qualified PPO network. In areas where an Exchange PPO network is not available, BCBSA will employ BlueCard PPO networks to fill in the gaps. The BlueCard program will provide access and favorable discounts for travelers and out-of-area resident members. If a Plan will not offer an Exchange PPO (or EPO) product in 2014, the Plan should send an email to Bluecardforexchanges@bcbsa.com by January 1, 2013. For additional information see section titled Composition of the Blue National Qualified Exchange PPO Network of this implementation guide. Important note for all Blue Plans related to BlueCard PPO Provider Data: Some Exchange PPO members may access the BlueCard PPO network. For this reason, BCBSA- supported directories for the BlueCard PPO network will also need to meet some Exchange requirements, including accurate display of providers not accepting new patients. Per IP Policy 1.18, Par/Host Plans are required to submit provider data to BCBSA in accordance with the Provider Data Plan Users Guide. Please see section above titled Federal Exchange Regulations for Provider Directories for important information on verifying the accuracy of information for providers that are not accepting new patients in BlueCard PPO provider data. Plans should verify that they are accurately populating data field P140 on the PDF. Data on Essential Community Providers
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Per the Federal Exchange regulations, Plans will be required to include Essential Community Providers in their networks accessed by Exchange members. BCBSA enhanced the Provider Data Format (PDF) (e_78202) with the ITS Release 12.0 Addendum so that Plans will be allowed to indicate which providers are essential community providers when submitting their provider data files. This enhancement was implemented on October 14, 2012. For files submitted after the implementation date, Plans may indicate that a provider is an Essential Community Provider. Please contact Debra Riebling (Debra.Riebling@bcbsa.com) with questions related to this enhancement.
Begin Making Local System Changes for Par/Host Pricing and Control/Home Plan Benefit Application
Recommended Completion Date: August 1, 2012 August 1, 2013 (Prior to ITS Release 13.0April 13, 2013) Plan Exchange Participation Level: All Plans must complete this step. Par/Host Plans should determine whether local system changes are needed to recognize new values on Plan Profiles and accurately populate the Submission Format (SF) for those claims. Control/Home Plans should determine whether local system changes are needed to recognize new values received on the SF and accurately apply benefits. Please review Chapter 3 on Systems for more detail on Par/Host Plan Pricing Scenarios, Control/Home Plan Benefit Scenarios, and the set-up of Plan Profiles. National Programs ITS Release 13.0 Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=24421 National Programs ITS Release 13.5 Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=24896 New ITS Values (ITS Release 13.0, April 13, 2013) New Delivery Methods: K Exchange Qualified PPO L Exchange Qualified PPO Custom New Account Type Codes: D Non-Exchange Individual Business E Exchange Individual Business F Exchange SHOP Business New Classifications of Providers: U Exchange Qualified Provider V Veterans Administration Exchange Qualified Provider 26

W Military Facility Exchange Qualified Provider X Exchange Qualified Custom Provider Y Veterans Administration Exchange Qualified Provider Z Military Facility Exchange Qualified Provider
Apply for Certification of a Product as a Qualified Health Plan (QHP) by the State-Run, Federal-Partnership, or Federally-Facilitated Exchange
Recommended Completion Date: March 1 August 1, 2013 (may vary by state) Plan Exchange Participation Level: PPO or EPO; Not Offering PPO or EPO Between January 1 and June 1, 2013, Plans need to submit required information to their local state-run Exchange, federal-partnership Exchange, or federally-facilitated Exchange to obtain certification of a product as a Qualified Health Plan (QHP). Please refer to your state or federally-facilitated Exchange website for additional information on QHP certification due dates and requirements. Once your Plan has received notification of approved QHP certification status, please send an email to Bluecardforexchanges@bcbsa.com including the following information: List of products certified to be offered on the Exchange (PPO, EPO, HMO, Traditional, etc.) Date of QHP certification Related PPO product/ network IDs BCBSA would like to track this information so that we know which products and networks are approved and will definitely be offered on Exchanges.
Complete Survey to Determine Inclusion in the National Exchange Qualified PPO Network
Recommended Completion Date: April 2013 Plan Exchange Participation Level: PPO or EPO In early Q2 2013, BCBSA will issue an all-Plan survey requesting information on Plans networks accessed by Exchange PPO or EPO members. Plans will be asked for information related to: inpatient, outpatient, and professional discounts for each network number of counties covered by each network number of counties in Plans licensed service area See Exhibit 7 for sample survey questions. The information received through this survey along with the provider data for the networks will be used by BCBSA to determine the composition of the Exchange Qualified PPO network.
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Submit Data for Physician Quality Measurement (PQM) and Blue Physician Recognition (BPR)
Recommended Completion Date (BPR): June 1, 2013 (Corresponds with provider data file (PDF) submission required date) Plan Exchange Participation Level: PPO or EPO Recommended Completion Date (PQM): July 30, 2013 (Corresponds with PQM quarterly update schedule) Plan Exchange Participation Level: PPO or EPO In order to ensure that the National Doctor and Hospital Finder is set-up for Exchange business, Plans will need to submit Physician Quality Measurement data (PQM) and Blue Physician Recognition (BPR) Data to BCBSA for any new Exchange PPO networks, so that the information can be displayed. Please contact Mary Conlisk (Mary.Conlisk@bcbsa.com) with questions related to PQM or BPR. Physician Quality Management Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703310?docId=19919
Submit Pricing Methods and Rule Combinations for New Exchange PPO Networks
Recommended Completion Date: July 1, 2013 Plan Exchange Participation Level: PPO or EPO Exchange members will have access to the National Exchange Qualified PPO Network, BlueCard PPO and Traditional Networks, negotiated arrangements PPO, Traditional and custom networks beginning on January 1, 2014. For BlueCard PPO and Traditional pricing, negotiated arrangements, and custom networks pricing, if Par/Host Plans received approval for their pricing method/rules combinations, no action is needed (unless new combinations are necessary). For any Exchange PPO networks (different than BlueCard PPO or existing custom networks), Par/Host Plans should submit to BCBSA by July 1, 2013 a completed and properly signed Application/Change Request Form for the pricing method/rules combinations proposed to be used when Exchange members access those networks. A new Application/Change Request form for Qualified PPO pricing method/rules combinations will be available on BlueWeb in early 2013. BCBSA will review the pricing method/rules combinations for Exchange PPO networks (different than BlueCard PPO) submitted by Plans to ensure compatibility with current Program requirements and conformance with ITS Release 13.0 requirements. Approved pricing methods/rules combinations will be posted to Blue Web. See links below for additional information.
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BlueCard Program Pricing Method/Rules Combinations BlueWeb Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/708050?docId=12337 Non-Participating Provider Pricing Method/Rules Combinations BlueWeb Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/708050?docId=16997 Negotiated Arrangement Custom Networks Pricing Method/Rules Combinations BlueWeb Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/708050?docId=20880 Instructions for Submission of Pricing Method/Rules Combination Request Forms The Uniform Pricing Facility (UPF) supports a wide range of Plan discount agreements for both institutional and professional claims at the line-item level, claim level and a combination of lineitem and claim-level pricing. For more information on determining the appropriate pricing method/rules combinations to accurately represent your Plan's contractual provider reimbursement terms, refer to the Uniform Pricing Facility ITS User Manual, Chapter 3, Local Claims Pricing, on BlueWeb: http://bluewebportal.bcbs.com/landingpagelevel3/701800?docId=17304 The following UPF rules (no-share rules) are not valid for Inter-Plan Business claims (Plan profile program code A) except for Plans exempted by state law. 001, 002, 004, 006, 007, 008, 010, 015, 016, 018, 019, 021, and, 022 029, 030, 032, 034, 035, 036, 038, 043, 044, 046, 047, 049, and 050 057, 058, 060, 062, 063, 064, 066, 071, 072, 074, 075, 077, and 078 Par/Host Plans should send an email to Patricia Carroll (patricia.carroll@bcbsa.com) by July 1, 2013 to submit the Application/Change Request Form for approval of the pricing method/rules combinations. Claims Pricing BlueWeb Reference Page For more information on claim pricing, refer to the ITS Uniform Pricing Facility (UPF) User Manual, chapter 3, Local Plan Pricing Options: http://bluewebportal.bcbs.com/landingpagelevel3/709050?docId=1802 Exchange Pricing Requirements Program Delivery Methods Code A A A 2 K 1
Network Type BlueCard PPO Qualified PPO BlueCard Traditional
Pricing Full pricing including non-par pricing Full pricing including non-par pricing Full pricing including non-par pricing 29

Network Type Negotiated Arrangements - Custom Network - AltNet Negotiated Arrangements - Custom Network Blue Precision Negotiated Arrangements- Custom Network Qualified PPO Negotiated Arrangements Other than Custom Networks Exchange Pricing Requirements Program Delivery Methods Code A or 1 J Pricing Full pricing including non-par pricing Full pricing including non-par pricing
A or 1
G, H, I
A or 1
Full pricing including non-par pricing Full pricing including non-par pricing
0, 1, 2, 3, 5 or K
Set-up Plan Profiles

Recommended Completion Date: April 15 September 1, 2013 Plan Exchange Participation Level: PPO or EPO; Not Offering PPO or EPO Exchange members will be set up to view providers in the appropriate network to which they have access, based on Plan Profiles. Plans will need to create Plan Profiles with a unique, Planspecific alpha prefix for Exchange members. Plans need to set up Plan Profiles for Exchange members by September 1, 2013 to ensure that members will be able to access directories for open enrollment beginning in October 2013. The alpha prefixes can be obtained through the IPO Data Lists, Plan Code, Alpha Prefix Registry & Request Forms website on BlueWeb at: http://blueweb.bcbs.com/blueweb/Leaf?docId=13484. Please see Chapter 3 on systems for more detail on setting up Plan Profiles. Please contact Elana Glover (Elana.Glover@bcbsa.com) with questions on setting up Plan Profiles.
Prepare New Disclosure Language

Recommended Completion Date: August 1, 2013 Plan Exchange Participation Level: PPO or EPO; Not Offering PPO or EPO but offering other products Control/Home Plans will need to prepare to include new disclosure language for all Exchange individual and group (insured and ASO) business with member materials by August 1, 2013 to prepare for the Exchange open enrollment period beginning October 2013.
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Revised disclosure language provisions for Exchange individual and group products will be incorporated into the revised Inter-Plan Programs disclosure language overhaul expected to be taken through Q3 2013 Governance Cycle for potential approval in September 2013. The revised provisions for Exchange products includes language explaining that federal law may mandate liability calculation methods different from those normally used for Inter-Plan arrangements. The memo sent out on August 30, 2012 (IPP-M-12-109) provides Plans with an interim solution for submitting proposed disclosure language when filing products with state regulators prior to Board approval in 2013. Please see Exhibit 3 for an example of Exchange disclosure language proposed to be included in Exchange member materials. IPP disclosure documents will potentially be revised for the following Exchange-related documents: PPO/Traditional self-funded account contracts PPO/Traditional insured account contracts Local HMOs with Out-of-Area Benefits self-funded account contracts Local HMOs with Out-of-Area Benefits insured account contracts PPO/Traditional and Local HMOs with Out-of-Area Benefits member benefit booklets/individual insured contracts Please contact Andrew Korsak (andrew.korsak@bcbsa.com) for questions on to Exchangerelated disclosure language. IP Policy Reference: 3.11 - Disclosures
Alpha Prefix Set-up for National Doctor and Hospital Finder/ BlueCard Access Call Center/ Mobile App
Recommended completion date: September 1, 2013 Plan Exchange Participation Level: PPO or EPO Exchange PPO members will automatically be set up to be given information on the Blue providers in the Qualified PPO, BlueCard PPO, or BlueCard Traditional Network by typing their alpha prefix into the National Doctor and Hospital Finder website, Mobile version or Mobile App, or by providing their alpha prefix when calling the BlueCard Access Call Center. Alpha Prefix Set-Up for Directories Exchange members will be set up to view the providers to which they have access as follows: Exchange PPO members set up to access the Qualified PPO network (Delivery Method K) will be given information on providers in the Qualified PPO network Exchange PPO members set up to access the BlueCard PPO network (Delivery Method 2) will be given information on providers in the BlueCard PPO network.
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Exchange PPO, HMO, Traditional and POS members set up to access the Traditional network (Delivery Method 1) will be given information on providers in the Traditional network.
Alpha prefixes for Exchange members with access to BlueCard PPO or the Traditional Network will be set-up to allow members to view providers in the appropriate network after the Plan Profile is set-up (approximately three weeks after Plan Profiles are set-up). Alpha prefixes for Exchange members with access to the new National Qualified PPO Network will be set-up to allow members to view providers in the appropriate network after the Plan profile is set-up, but no earlier than September 1, 2013. BCBSA will need to receive Exchange PPO provider data from Plans, validate the data and send it to vendors, as well as test the directories before displaying the Qualified PPO provider data. Exchange members will be able to view providers in directories prior to the effective date of their coverage. Plans will need to be sure to set-up plan profiles no later than September 1, 2013, so that alpha prefixes will be set up for directories prior to open enrollment. Custom Network Arrangements If Exchange members are set-up to access a custom network (Delivery methods G, H, I, J, L), please send an email to NAAEntry@bcbsa.com for the set-up of those alpha prefixes. The NAA Entry Instructions link below provides Plans with instructions for submitting a custom arrangement request via the Entry Form. The instructions ensure that the correct logic will be applied for members who access the National Doctor and Hospital Finder website, Blue Access Call Center, Mobile App, and the National Consumer Cost Tool (NCCT) with their alpha prefix. This information identifies members that are covered by custom delivery arrangements, such as those which are made between Control/Home Plans and a Par/Host Plan within an overlapping service area. Once completed, email the appropriate Entry Form to NAAEntry@bcbsa.com. NAA Entry Instructions: http://bluewebportal.bcbs.com/landingpagelevel3/702300?docId=8549 Special Requests or Alpha Prefix Confirmation for Directories If your Plan has any special needs related to the set-up of their Exchange members alpha prefixes for directories or if your Plan would like to confirm the set-up of its Exchange member alpha prefix, send an email to NAAEntry@bcbsa.com. Consumer Functionality Consumers (members and prospective members) will also be able to search for providers without an alpha prefix. Guest functionality is already set-up so members or prospective members can view the BlueCard PPO or BlueCard Traditional network. An enhancement will be made to
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allow for members or prospective members to view Qualified PPO network providers without an alpha prefix. This capability will be viewable by consumers in September 2013. Special Exchange Marketing Material Requirements Federal Marketing Material Requirements Federal regulations require all QHP issuers to identify providers not accepting new patients in their provider directories. For additional information on provider data, please see section titled Requisition of Product/Network IDs & Submission of Provider Data for Networks Accessed by Exchange PPO Members. This capability to display providers not accepting new patients will be part of the Qualified PPO and BlueCard directories when they are available in September 2013. Costs for Enhancements Related to Federal Marketing Material Requirements The enhancements related to federal marketing requirements will be charged to all Blue Plans through Grand Billing, based on each Plans utilization of the website, as the enhancement supports the entire Blue system. State Exchange Marketing Material Requirements Plans should notify BCBSA of any special state-run Exchange or federally-facilitated Exchange marketing material requirements for the National Doctor and Hospital Finder website, BlueCard Access Call Center, or Mobile App. For BlueCard Access Call Center requirements, please notify Bill Witt (william.witt@bcbsa.com) by February 1, 2013. For National Doctor and Hospital Finder or Mobile App requirements, please notify Denise Sykes (denise.sykes@bcbsa.com) by February 1, 2013. Costs for Enhancements Related to State Exchange Marketing Requirements Any enhancements related to state-specific marketing requirements will be charged through Grand Billing to those Plans requesting the enhancements.
Provider Education
Recommended Completion Date: August 1, 2013 Plan Exchange Participation Level: All Plans must complete this step. Par/Host Plans should educate their participating providers on Exchange business by August 1, 2013. Please see Exhibit 4 for the BCBSA templates of provider education materials for Exchange business (these materials will be developed in first quarter 2013).
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Please contact Cathy Reice (Catherine.Reice@bcbsa.com) with questions related to provider education. Provider and Member Education Material Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/704050?docId=14260
Member Education
Recommended Completion Date: August 1, 2013 Plan Exchange Participation Level: PPO or EPO; Not Offering PPO or EPO but offering other products. Control/Home Plans should develop member education materials so they are prepared to educate potential Exchange members by August 1, 2013. Please contact Cathy Reice (Catherine.Reice@bcbsa.com) with questions related to member education. Provider and Member Education Material Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/704050?docId=14260
Internal Customer Service Staff Training

Recommended Completion Date: August 1, 2013 Plan Exchange Participation Level: All Plans must complete this step. Plans should educate their internal staff on Exchange business by August 1, 2013. The InterPlan Programs Staff Training modules will be updated in first quarter 2013 to include a new section on Exchange business. Please see the Inter-Plan Program Staff Training BlueWeb page for information on training curriculum. Please contact Amy Taylor (amy.taylor@bcbsa.com) with questions related to provider education. Inter-Plan Programs Staff Training Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/704100?docId=21944
Produce ID Cards for Exchange Members with the Correct Suitcase Logo Indicating Out-of-Area Network Access
Recommended Completion Date: August 1, 2013 Plan Exchange Participation Level: PPO or EPO; Not Offering PPO or EPO but offering other products In the third quarter of 2012, changes to Policy were approved requiring the inclusion of a new network indicator on ID cards for members with access to the National Exchange Qualified PPO 34

Network. Control/Home Plans should include new PPO B logo, upon issuance of member ID Cards for Exchange members with access to the new National Qualified PPO Network. Plans should refer to the Brand Regulations for specific positioning of the graphic on the face of the ID card.
Member ID cards for public Exchange members with access to the BlueCard PPO or BlueCard Traditional network should include the PPO Suitcase logo or the empty suitcase logo, respectively.
Submit Cost Data for Exchange Networks to the National Consumer Cost Tool (NCCT)
Recommended Completion Date: July 1 - September 30, 2013. Plan Exchange Participation Level: PPO or EPO In accordance with IP Policy 1.19, National Consumer Cost Tool, Par/Host Licensees must submit their provider cost estimate data to BCBSA for their BlueCard PPO and custom networks. In order to ensure the National Consumer Cost Tool is set-up for exchange business, Plans will need to submit NCCT provider cost estimate data for providers in any new Exchange Qualified PPO networks by September 30, 2013. Please contact Mike Dowd (mike.dowd@bcbsa.com) with questions related to the submission of NCCT data. National Cost Consumer Tool Reference Page: http://bluewebportal.bcbs.com//landingpagelevel3/703310?docId=20332
Complete Global Certification for ITS Release 13.5

Recommended Completion Date: July 1 - September 30, 2013 Plan Exchange Participation Level: All Plans must complete this step.
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Plans will need to complete Global Certification for Exchange business with ITS Release 13.5 by September 30, 2013. Please contact your Plans BCBSA implementation specialist via BCBSA help desk with questions related to Global Certification. National Programs ITS Release 13.5 Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=24896
Prepare to Send Network Alerts for new Exchange PPO Networks

Recommended Completion Date: December 1, 2013 Plan Exchange Participation Level: PPO or EPO By December 1, 2013, Par/Host Plans should ensure they are prepared to notify Control/Home Plans of significant changes (e.g., early warnings, provider cancellations, additions, renewals, reinstatements) to their Exchange PPO provider networks that may impact Control/Home Plans' members beginning January 1, 2014. Par/Host Plans must send network alerts in accordance with Inter-Plan Programs Policy IP 1.06 Par/Host Licensee Functions and Responsibilities and Inter-Plan Programs Processing Standard IPS 1.01 Network Alerts. Par/Host Plans should use the BlueCard network alert template to communicate significant changes to their Exchange PPO provider networks. Network alerts are created in an Excel template found at the BlueWeb link below and should be communicated to Plans in a secure format using Inter-Plan Programs Directory (IPPD) distribution lists. Complete instructions for BlueCard Provider Network Alerts can also be found on BlueWeb: (http://bluewebportal.bcbs.com/landingpagelevel3/702300?docId=2179) Please contact Nancy Williams (Nancy.Williams@bcbsa.com) with questions related to InterPlan Provider Network Alerts. Inter-Plan Provider Network Alert Overview and Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/702300?docId=2179
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VERSION 1.0 January 10, 2013 CHAPTER 3: SYSTEMS

The implementation of BlueCard for Public Exchange Products involves operational changes for both Control/Home and Par/Host Plans. Par/Host Plans should determine whether local system changes are needed to recognize new values on Plan Profiles and accurately populate the Submission Format (SF) for those claims. Control/Home Plans should determine whether local system changes are needed to recognize new values received on the SF and accurately apply benefits. In order to support Exchange business, BCBSA will make the enhancements below in ITS Release 13.0. The scheduled release date for ITS 13.0 is November 8, 2012 and the scheduled implementation date is April 14, 2013. The release date for ITS Release 13.5 is May 9, 2013; the scheduled implemented date is October 13, 2013. ITS Release 13.5 will also include some enhancements related to BlueCard for Exchanges. All Global Certification related to BlueCard For Public Exchange Products will take place with ITS Release 13.5. National Programs ITS Release 13.0 Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=24421 National Programs ITS Release 13.5 Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=24896 New ITS Values (ITS Release 13.0) New Delivery Methods: K Qualified PPO L Qualified PPO Custom New Account Type Codes: D Non-Exchange Individual Business E Exchange Individual Business F Exchange SHOP Business New Classifications of Providers: U Exchange Qualified Provider V Veterans Administration Exchange Qualified Provider W Military Facility Exchange Qualified Provider X Exchange Qualified Custom Provider Y Veterans Administration Exchange Qualified Provider Z Military Facility Exchange Qualified Provider ITS Release 13.5 will also include Exchange enhancements needed prior to January 1, 2014. Some enhancements include the following: 37

New DF message code for the individual grace period. New BlueSquared info message code for individual grace period. New adjustment reason code for individual grace period. Blue Precision functionality for Exchange business.
Par/Host Plan Pricing Scenarios

The Par/Host Pricing scenarios below are included to assist Par/Host Plans in populating the Submission Format (SF) for Exchange members with access to the new Qualified PPO network as well as existing networks for Exchange business. The scenarios provide examples on how to populate the following data fields: Classification of Provider (C023 or C052), Provider/Network Availability Indicator (P096), and Provider Specialty Type Availability Indicator (P097 or P171). The scenarios have been created for Exchange members with the following types of products: A. Exchange PPO member with out-of-area access to Qualified PPO network. B. Exchange PPO member with out-of-area access to BlueCard PPO network. C. Exchange PPO member with out-of-area access to Qualified PPO Custom network. D. Exchange PPO member with out-of-area access to AltNet network. E. Exchange PPO member with out-of-area access to Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. F. Exchange PPO member with out-of-area access to Blue Precision custom network and Traditional wrap in the custom arrangement service area. G. Exchange PPO member with out-of-area access to Blue Precision custom network and no wrap in the custom arrangement service area. H. Exchange PPO, Traditional, HMO, or POS member with out-of-area access to Traditional network. Legend of ITS field values: The fields in blue are new values for BlueCard for Exchanges (ITS Release 13.0) and are subject to change based on final functional specifications (completed Fall 2012). Program Codes A = Inter-Plan Business 1 = Custom Delivery Methods 1 = Traditional 2 = BlueCard PPO 3 = Point of Service (not included in scenarios) 5 = HMO (not included in scenarios) J = AltNet Networks G = Custom Network with PPO Wrap H = Custom Network with Classification of Provider 1 = Participating Provider 3 = Non-Participating Provider 5 = PPO 9 = Unsolicited Provider D = Veterans Administration ProviderParticipating E = Veterans Administration Provider- NonParticipating F = Military Facility- Participating 38

Program Codes Delivery Methods Traditional Wrap I = Custom Network with No Wrap K = Qualified PPO L = Qualified PPO Custom Classification of Provider G = Military Facility- Non-Participating J= AltNet Network Provider K = Veterans Administration- AltNet L = Military Facility- AltNet P = Custom Network Provider Q = Veterans Administration Provider Blue Precision R = Military Facility Blue Precision S = Veterans Administration Provider PPO T = Military Facility- PPO U = Qualified PPO Provider V= Veterans Administration Exchange Qualified Provider W= Military Facility Exchange Qualified Provider X = Qualified PPO Custom Provider Y= Veterans Administration Exchange Qualified Custom Provider Z= Military Facility Exchange Qualified Custom Provider NOTE: Program Code 8 is not included in these scenarios because NASCO to NASCO claims do not use the Submission Format.
39

A. Exchange PPO member with out-of-area access to the Qualified PPO network. The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the Qualified PPO pre-deployed network (Program Code A or 1, Delivery Method K). When Delivery Method equals K: P096 is required when C023 U, V or W. P097 or P171 is required when C023 U, V or W and P096 N Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Qualified PPO network does not go to a provider in the network, but is treated by either a Qualified PPO Custom, BlueCard PPO or a BlueCard Traditional Provider. In these situations, the Qualified PPO Custom, BlueCard PPO, or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: 5, S, or T X, Y, or Z 1, D, or F 3, E, or G
*An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Par/Host Plans will not populate these classifications of providers on claims with Delivery method K. This implies that Altnet and Blue Precision discounts will not apply for these members. Provider Classifications for Members with Delivery Methods K When Provider Is Not When Provider Is Qualified PPO Network Type Included in the National Included in the National Qualified PPO Network Qualified PPO Network BlueCard PPO 5, S, or T Altnet Custom J, K, or L U, V or W Blue Precision Custom P, Q, or R New Exchange Qualified PPO X, Y, or Z Custom For Service Areas Where a Qualified PPO Network is Not Available In Blue service areas where a Qualified PPO Network is not available, BlueCard PPO providers will be considered in-network for members with access to the Qualified PPO pre-deployed network (Delivery Method K). 40

In service areas where a Qualified PPO network is not available (P096 =N), the BlueCard PPO network must be available to the member. In these portions of a service area, Par/Host Plans should always pass the BlueCard PPO rate and provider classifications (5, S, or T) as they would for members with Delivery Method 2. Please see scenario A3 for more detail on how these claims would be handled. This will ensure that Exchange members receive BlueCard PPO discounts when they see BlueCard PPO providers in areas where Qualified PPO Networks are not available. Network Availability and Provider Type Availability Indicators BCBSA is proposing to be more definitive related to how Network Availability and Provider Type Availability indicators are populated on claims for Exchange members with access to the Qualified PPO network (Delivery Method = K). By doing this, Control/Home Plans will receive more detailed information on whether an Exchange PPO member was in an area where a network meeting Exchange standards was available or not, and may apply benefits appropriately. Network Availability Indicator (P096) When the Network Availability Indicator is required, for members set up with Delivery Method K, the Par/Host Plan should populate the network availability indicator with a Y, if an Exchange network that meets Exchange network standards is available in the county where services were rendered. This will ensure that if the member does not have access to a network that meets Exchange standards, the Control/Home Plan will know and can apply member benefits appropriately. If the member receives services in a county where either there are providers that are part of the Qualified PPO network, but the network does not meet Exchange network standards or there is no Exchange PPO network, the Network Availability indicator should be populated with an N. For members set up to access the Qualified PPO network, network availability could be Y or N (see scenario A1). Example: An Exchange has approved the portion of the Blue Qualified PPO network in Apple County. The Plans Qualified PPO network includes a few providers that are in the next county over, Orange County. However, the network does not meet Exchange network standards in Orange County. When a Qualified PPO member (Delivery Method K) is treated by providers in Apple County, the Par/Host Plan will populate the network availability indicator with Y. When a Qualified PPO member (Delivery Method K) is treated by providers in Orange County, the network availability indicator should be populated with N.
Provider Type Availability Indicator (P097 or P171) When the Provider Type Availability Indicator is required, for members set up with Delivery Method K, the Par/Host Plan should populate the Provider Type Availability indicator with a Y, if a provider of the specialty desired is available in the county where services were rendered.
41

Example: An Exchange member is not treated by a provider in the Qualified PPO Network. The member is treated by an out-of-network pediatrician in Orange County. The Par/Host Plan has a pediatrician in the Qualified PPO network in Orange County. When a Qualified PPO member (Delivery Method K) is treated by on out-of-network pediatrician in Orange County, the Provider Type Availability indicator would be populated with a Y.
Trad Contract Covers Mbrs PPO Contract Covers Mbrs # Variables Prgm Code Dlvy Mthd Class of Provider (CP) Netwo rk Avail (NA) Provider Type Avail
Data Element A1 Serviced by Qualified PPO provider Qualified PPO network is OR is not available Provider specialty desired is available in the Qualified PPO network Serviced by BlueCard PPO provider Qualified PPO network is available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by BlueCard PPO provider Qualified PPO network is not available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by BlueCard Traditional provider Qualified PPO network is available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by BlueCard Traditional provider Qualified PPO network is not available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by Non-Participating provider Qualified PPO network is available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by Non-Participating provider Qualified PPO network is not available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by Qualified PPO Custom provider Qualified PPO network is available Provider specialty desired is OR is not available in the Qualified PPO network Serviced by Qualified PPO Custom provider Qualified PPO network is not available
P079 A or 1
D012 K X
C023 or C052 U, V or W
P096 Y, N, or BLAN K Y
P097 or P171 Y or BLANK
A2
*
A3
A or 1
K X
1 , D or F 3 , E or G 5 , S or T 5 , S or T
Y or N
A or 1
Y, N, or BLANK
A4
*
A5
A or 1
1 , D or F 3 , E or G
Y or N
*
A6
A or 1
1 , D or F 3 , E or G
Y, N or BLANK
A or 1
3, E or G
Y or N
A7
A or 1
3, E or G
Y, N, or BLANK
A8
*
A9
A or 1
K X
1, D or F 3, E, or G X, Y, or Z
Y or N
A or 1
1, D or F 3, E, or G
Y, N, or BLANK
42

Trad Contract Covers Mbrs PPO Contract Covers Mbrs # Variables Prgm Code Dlvy Mthd Class of Provider (CP) Netwo rk Avail (NA) Provider Type Avail
Data Element
P079
D012 X
*
A10
A11
Provider specialty desired is OR is not available in the Qualified PPO network Serviced by Unsolicited Provider Qualified PPO network is available Provider specialty desired is not available in the Qualified PPO network Serviced by Unsolicited Provider Qualified PPO network is not available Provider specialty desired is not available in the Qualified PPO network
C023 or C052 X, Y, or Z 9
P096
P097 or P171
A or 1
A or 1
43

B. Exchange PPO member with out-of-area access to BlueCard PPO network The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the BlueCard PPO network (Program Code A or 1, Delivery Method 2). Generally, Exchange member claims with a delivery method 2 should be handled the same way that claims with a Delivery Method of 2 are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W, X, Y, Z) when the discount applies for Exchange members. Par/Host Plans will need to look at the Delivery Method (2) and Account Type Codes (E or F) to identify Exchange members with access to the BlueCard PPO network. When Delivery Method equals 2: P096 is required when C023 5, S, or T P097 or P171 is required when C023 5, S, or T and P096 N Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the BlueCard PPO network does not go to a provider in the network, but is treated by either a Qualified PPO or a BlueCard Traditional Provider. In these situations, the Qualified PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will classify these providers with: U, V, or W 1, D, or F 3, E, or G X, Y, or Z *An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method 2. This implies that Altnet and Blue Precision discounts will not apply for these members. Network Availability and Provider Type Availability Indicators Currently, Par/Host Plans use their own logic to determine how to populate the Network Availability and Provider Type Availability indicators on claims for members with access to the BlueCard PPO Network. Typically, if there are network providers in the area where the claim was incurred, the Par/Host Plan will populate the Network Availability indicator with a Y. If there are no network providers available where the claim was incurred, the network availability indicator is typically populated with an N. The same logic typically may also apply when Par/Host Plans are populating the Provider Type Availability Indicator. Network Adequacy is not a required factor for Par/Host Plans to consider when populating these fields for the BlueCard PPO network.
44

Network Availability Indicator: If a member is treated by an in-network provider, typically the Network Availability indicator will be populated with Y, if the Par/Host Plan decides to populate the field. The assumption here is that if a member was able to see a provider in the network, then a network must have been available without regard to the adequacy of the network. To allow for system flexibility, Par/Host Plans may also populate the Network Availability indicator with an N. Provider Type Availability Indicator: If a network was not available, Par/Host Plans will typically populate the Provider Type Availability field with an N, if the Par/Host Plan decides to populate the field. The assumption here is that if a network was not available, then a provider of the specialty desired must have not been available. To allow for system flexibility, Par/Host Plans may also the Provider Type Availability indicator with a Y.
Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prgm Code Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provide r Type Avail
Variables
Data Element B1 Serviced by BlueCard PPO provider BlueCard PPO network is OR is not available Provider specialty desired is available in the BlueCard PPO network. Serviced by Qualified PPO provider BlueCard PPO network is available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by Qualified PPO provider BlueCard PPO network is not available Provider specialty desired is OR is not available in the BlueCard PPO network.
P079 A or 1
D012 2 X
C023 or C052 5 , S or T
P096 Y or BLANK N is valid Y
P097 or P171 Y or BLAN K
B2
*
B3
A or 1
2 X
1, D or F 3, E or G U, V or W 1, D or F 3, E or G U, V or W
Y or N
A or 1
N or BLAN K Y is valid
B4
*
B5
Serviced by BlueCard Traditional provider BlueCard PPO network is available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by BlueCard Traditional provider BlueCard PPO network is not available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by Non-Participating provider BlueCard PPO network is available Provider specialty desired is OR is not
A or 1
1, D or F 3, E or G
Y or N
A or 1
1, D or F 3, E or G
N or BLAN K Y is valid Y or N
B6
A or 1
3, E or G
45

# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prgm Code Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provide r Type Avail
Data Element available in the BlueCard PPO network. Serviced by Non-Participating provider BlueCard PPO network is not available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by Qualified PPO Custom provider BlueCard PPO network is available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by Qualified PPO Custom provider BlueCard PPO network is not available Provider specialty desired is OR is not available in the BlueCard PPO network. Serviced by Unsolicited provider BlueCard PPO network is available Provider specialty desired is not available in the BlueCard PPO network. Serviced by Unsolicited provider BlueCard PPO network is not available Provider specialty desired is not available in the BlueCard PPO network.
P079
D012
C023 or C052 3, E or G
P096
P097 or P171 N or BLAN K Y is valid Y or N
B7
A or 1
B8
*
B9
A or 1
1, D or F 3, E or G X, Y, or Z
X A or 1 2 X X
1, D or F 3, E or G X, Y, or Z
N or BLAN K Y is valid N
B10
A or 1
B11
A or 1
46

C. Exchange PPO member with out-of-area access to Qualified PPO Custom network The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the Qualified PPO custom network (Program Code 1 or A, Delivery Method L). Within the custom arrangement service area, the member only has in-network access to the Qualified PPO Custom Network. The member may also be set up to have national access to the BlueCard PPO or Qualified PPO pre-deployed network outside of the custom arrangement service area (Program Code A, Delivery Method K or 2). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. When Delivery Method equals L: P096 is required when C023 X, Y, or Z P097 or P171 required when C023 X, Y, or Z and P096 N Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Qualified PPO Custom Network does not go to a provider in the network, but is treated by either a Qualified PPO, BlueCard PPO or a BlueCard Traditional Provider. In these situations, the Qualified PPO, BlueCard PPO, or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: U, V, or W 5, S, or T 1, D, or F 3, E, or G *An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method L. This implies that Altnet and Blue Precision discounts will not apply for these members. Network Availability and Provider Type Availability Indicators BCBSA is proposing to be more definitive related to how Network Availability and Provider Type Availability indicators are populated on claims for Exchange members with access to the Qualified PPO custom network (Delivery Method = L). By doing this, Control/Home Plans will receive more detailed information on whether an Exchange PPO member was in an area where a network meeting Exchange standards was available or not, and may apply benefits appropriately. Network Availability Indicator (P096) 47

When the Network Availability Indicator is required, for members set up with Delivery Method L, the Par/Host Plan should populate the network availability indicator with a Y, if an Exchange network that meets Exchange network standards is available in the county where services were rendered. This will ensure that if the member does not have access to a network that meets Exchange standards, the Control/Home Plan will know and can apply member benefits appropriately. If the member receives services in a county where either there are providers that are part of the Qualified PPO custom network, but the network does not meet Exchange network standards or there is no Exchange PPO network, the Network Availability indicator should be populated with an N. For members set up to access a Qualified PPO custom network, network availability could be Y or N when it is required (see scenario C1). Example: An Exchange has approved the portion of the Qualified PPO custom network in Apple County. The Plans Qualified PPO network includes a few providers that are in the next county over, Orange County. However, the network does not meet Exchange network standards in Orange County. When a Qualified PPO member (Delivery Method L) is treated by providers in Apple County, the Par/Host Plan will populate the network availability indicator with Y. When a Qualified PPO member (Delivery Method L) is treated by providers in Orange County, the network availability indicator should be populated with N.
Provider Type Availability Indicator (P097 or P171) When the Provider Type Availability Indicator is required, for members set up with Delivery Method L, the Par/Host Plan should populate the Provider Type Availability indicator with a Y, if a provider of the specialty desired is available in the county where services were rendered. Example: An Exchange member is not treated by a provider in the Qualified PPO Network. The member is treated by an out-of-network pediatrician in Orange County. The Par/Host Plan has a pediatrician in the Qualified PPO network in Orange County. When a Qualified PPO member (Delivery Method L) is treated by on out-of-network pediatrician in Orange County, the Provider Type Availability indicator would be populated with a Y.
# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prg mCo de Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provider Type Avail
Data Element C1 Serviced by Qualified PPO Custom provider Qualified PPO Custom network is OR is not available Provider specialty desired is available in the Qualified PPO Custom Network Serviced by Qualified PPO provider
P07 9 1 or A
D012 L X
C023 or C052 X, Y, or Z
P096 Y, N, or BLANK
C2
1 or
1, D or F
Y or N
48

# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prg mCo de Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provider Type Avail
Data Element
*
C3
*
C4
Qualified PPO Custom network is available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by Qualified PPO provider Qualified PPO Custom network is not available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by BlueCard PPO provider Qualified PPO Custom network is available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by BlueCard PPO provider Qualified PPO Custom network is not available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by BlueCard Traditional provider Qualified PPO Custom network is available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by BlueCard Traditional provider Qualified PPO Custom network is not available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by Non-Participating provider Qualified PPO Custom network is available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by Non-Participating provider Qualified PPO Custom network is not available Provider specialty desired is OR is not available in the Qualified PPO Custom Network Serviced by Unsolicited provider Qualified PPO Custom network is available Provider specialty desired is not available in the Qualified PPO Custom Network Serviced by Unsolicited provider Qualified PPO Custom network is not available Provider specialty desired is not available in the Qualified PPO Custom Network
P07 9 A
D012
C023 or C052 3, E or G X U, V or W X X 1, D or F 3, E or G U, V or W X X 1 , D or F 3 , E or G 5 , S or T X X 1 , D or F 3 , E or G 5 , S or T 1 , D or F 3 , E or G
P096
P097 or P171
1 or A
Y, N, or BLANK
*
C5
1 or A
Y or N
*
C6
1 or A
Y, N, or BLANK
*
C7
1 or A
Y or N
*
C8
1 or A
1 , D or F 3 , E or G
Y, N or BLANK
1 or A
3, E or G
Y or N
C9
1 or A
3, E or G
Y, N, or BLANK
C10
1 or A
C11
1 or A
D. Exchange PPO Custom member with out-of-area access to AltNet network 49

The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the AltNet network (Program Code 1 or A, Delivery Method J). Within the custom arrangement service area, the member only has in-network access to the AltNet Network. The member may also be set up to have national access to the BlueCard PPO or Qualified PPO pre-deployed network outside of the custom arrangement service area (Program Code A, Delivery Method K or 2). Generally, Exchange member claims with a delivery method J should be handled the same way that claims with a Delivery Method of J are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W) when the discount applies for Exchange members. Par/Host Plans will need to look at the Delivery Method (J) and Account Type Code (E or F) to identify Exchange members with access to an Altnet network. The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. When Delivery Method equals J: P096 is required when C023 J, K, or L P097 or P17 required when C023 J, K, or L and P096 N Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Altnet Network does not go to a provider in the network, but is treated by a Qualified PPO, BlueCard PPO or a BlueCard Traditional Provider. In these situations, the Qualified PPO, BlueCard PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: U, V, or W 5, S, or T 1, D, or F 3, E, or G *An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z) and Blue Precision (P, Q, or R). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method J. This implies that Qualified PPO Custom and Blue Precision discounts will not apply for these members. Network Availability and Provider Type Availability Indicators Currently, Par/Host Plans use their own logic to determine how to populate the Network Availability and Provider Type Availability indicators on claims for members with access to an 50

Altnet Network. Typically, if there are network providers in the area where the claim was incurred, the Par/Host Plan will populate the Network Availability indicator with a Y. If there are no network providers available where the claim was incurred, the network availability indicator is typically populated with an N. The same logic typically may also apply when Par/Host Plans are populating the Provider Type Availability Indicator. Network Adequacy is not a required factor for Par/Host Plans to consider when populating these fields for the Altnet network. Network Availability Indicator: If a member is treated by an in-network provider, typically the Network availability indicator will be populated with Y, if the Par/Host Plan decides to populate the field. The assumption here is that if a member was able to see a provider in the network, then a network must have been available without regard to the adequacy of the network. To allow for system flexibility, Par/Host Plans may also populate the Network Availability indicator with an N. Provider Type Availability Indicator: If a network was not available, Par/Host Plans will typically populate the Provider Type Availability field with an N, if the Par/Host Plan decides to populate the field. The assumption here is that if a network was not available, then a provider of the specialty desired must have not been available. To allow for system flexibility, Par/Host Plans may also the Provider Type Availability indicator with a Y.
Data Element D1 Serviced by Custom Alt Net provider BlueCard PPO network is OR is not available Provider specialty desired is available in the AltNet network Serviced by BlueCard PPO provider AltNet network is available Provider specialty desired is OR is not available in the AltNet network Serviced by BlueCard PPO provider AltNet network is not available Provider specialty desired is OR is not available in the AltNet network Serviced by Qualified PPO provider AltNet network is available Provider specialty desired is OR is not available in the AltNet network
079 1 or A
D012 J X
Trad Contract Covers Mbrs
Variables
PPO Contract Covers Mbrs
Prg m Cod e
Dlvy Mthd
Class of Provider (CP)
Networ k Avail (NA)
Provider Type Avail
C023 or C052 J, K, or L
P096 Y or BLAN K N is allowed Y
D2
*
D3
1 or A
J X
1, D or F 3, E or G 5, S or T 1, D or F 3, E or G 5, S or T 1 , D or F 3 , E or G U, V or W
Y or N
*
D4
1 or A
J X
N or BLANK Y is valid Y or N
1 or A
J X
51

Trad Contract Covers Mbrs # Variables PPO Contract Covers Mbrs Prg m Cod e Dlvy Mthd Class of Provider (CP) Networ k Avail (NA) Provider Type Avail
Data Element D5 Serviced by Qualified PPO provider AltNet network is not available Provider specialty desired is OR is not available in the AltNet network Serviced by BlueCard Traditional provider AltNet network is available Provider specialty desired is OR is not available in the AltNet network Serviced by BlueCard Traditional provider AltNet network is not available Provider specialty desired is OR is not available in the AltNet network Serviced by Non-Participating provider AltNet network is available Provider specialty desired is OR is not available in the AltNet network Serviced by Non-Participating provider AltNet network is not available Provider specialty desired is OR is not available in the AltNet network Serviced by Unsolicited provider AltNet network is available Provider specialty desired is not available in the AltNet network Serviced by Unsolicited provider AltNet network is not available Provider specialty desired is not available in the AltNet network
079 1 or A
D012 J X X
*
D6
C023 or C052 1 , D or F 3 , E or G U, V or W 1 , D or F 3 , E or G
P096 N
P097 or P171 N or BLANK Y is valid Y or N
*
D7
1 or A
*
D8
1 or A
1 , D or F 3 , E or G
N or BLANK Y is valid
1 or A
3, E or G
Y or N
D9
1 or A
3, E or G
N or BLANK Y is valid N
D10
1 or A
D11
1 or A
E. Exchange PPO member with out-of-area access to Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the Blue Precision network (Program Code 1 or A, Delivery Method G). Within the custom arrangement service area, the member only has in-network access to the Blue Precision Network and BlueCard PPO Network. The member may also be set up to have national access to the BlueCard PPO or Qualified PPO pre-deployed network outside of the custom arrangement service area (Program Code A, Delivery Method K or 2). Generally, Exchange members claims with a delivery method G should be handled the same way that claims with a Delivery Method of G are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W) when the 52

discount applies for Exchange members. Par/Host Plans will need to look at the Delivery Method (G) and Account Type Code (E or F) to identify Exchange members with access to a Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. NOTE: Systems are not set up to allow for Blue Precision networks to be wrapped with the Qualified PPO network within the custom arrangement service area. The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. Please see current edits IRL2F and PRL1Q for detail on how Classification of Provider and Provider Type Availability will be required for members with access to Blue Precision custom networks. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/landingpagelevel3/703300?docId=15118 Network Availability N, Y, and 2 Not valid 1 Custom Network Available, BC Network (doesnt matter) 3 Custom Network not Available, but PPO Network Available 4 Neither Custom Network or PPO Network Available Blank Provider Type Availability N, Y, and 2 Not valid 1 Custom Network Available (Only Used when Delivery Method = G, H or I) 3 Custom Network not Available, but PPO Network Available (Used only when Delivery Method = G) 4 Neither Custom Network or PPO Network Available (Used only when Delivery Method = G) Blank Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Blue Precision Network and BlueCard PPO network does not go to a provider in the network, but is treated by either a Qualified PPO, BlueCard PPO, or a BlueCard Traditional Provider. In these situations, the BlueCard PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: 5, S, or T 1, D, or F 3, E, or G U, V, or W 53

*An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method G. This implies that Qualified PPO Custom and Altnet discounts will not apply for these members.
Trad Contract Covers Mbrs PPO Contract Covers Mbrs # Variables Prg m Cod e Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provide r Type Avail
Data Element E1 E2 E3 E4 E5 Serviced by Blue Precision provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by BlueCard PPO provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is available in the Blue Precision network Provider specialty desired is OR is not available in the BlueCard PPO network Serviced by BlueCard PPO provider Blue Precision network is not available BlueCard PPO network is available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by BlueCard PPO provider Blue Precision network is not available BlueCard PPO network is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is not available in the BlueCard PPO network Serviced by Qualified PPO provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is available in the Blue Precision network Provider specialty desired is OR is not available in the BlueCard PPO network
P07 9 1 or A
D012 G X
C023 or C052 P, Q or R
P096 1 or BLANK
P097 or P171 1 or BLAN K
1 or A
G X
1 , D or F 3 , E or G 5, S or T
1 or A
1, D, or F 3, E, or G 5, S or T
3 or BLAN K
1 or A
1, D, or F 3, E, or G 5, S or T
4 or BLAN K
1 or A
G X
1 , D or F 3 , E or G U, V or W
54

Data Element E6 E7 E8 E9 E10 E11 E12 Serviced by Qualified PPO provider Blue Precision network is not available BlueCard PPO network is available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by Qualified PPO provider Blue Precision network is not available BlueCard PPO network is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is not available in the BlueCard PPO network Serviced by BlueCard Traditional provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by BlueCard Traditional provider Blue Precision network is not available BlueCard PPO network is available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by BlueCard Traditional provider Blue Precision network is not available BlueCard PPO network is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is not available in the BlueCard PPO network Serviced by Non-Participating provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by Non-Participating provider Blue Precision network is not available BlueCard PPO network is available
P07 9 1 or A
D012 G X X
C023 or C052 1 , D or F 3 , E or G U, V or W
P096 3
P097 or P171 3 or BLAN K
1 or A
1 , D or F 3, E, or G U, V, or W
4 or BLAN K
1 or A
1 , D or F 3 , E or G
1 or A
1 , D or F 3 , E or G
3 or BLAN K
1 or A
1 , D or F 3 , E or G
4 or BLAN K
1 or A
3, E or G
1 or A
3, E or G
3 or BLAN K
55

Data Element Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by Non-Participating provider Blue Precision network is not available BlueCard PPO network is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is not available in the BlueCard PPO network Serviced by Unsolicited provider Blue Precision network is available BlueCard PPO network is OR is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by Unsolicited provider Blue Precision network is not available BlueCard PPO network is available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is available in the BlueCard PPO network Serviced by Unsolicited provider Blue Precision network is not available BlueCard PPO network is not available Provider specialty desired is not available in the Blue Precision network Provider specialty desired is not available in the BlueCard PPO network
P07 9
D012
C023 or C052
P096
P097 or P171
E13
1 or A
3, E or G
4 or BLAN K
E14
1 or A
E15
1 or A
3 or BLAN K
E16
1 or A
4 or BLAN K
F. Exchange PPO member with out-of-area access to Blue Precision custom network and Traditional wrap in the custom arrangement service area. The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access the Blue Precision network (Program Code 1 or A, Delivery Method H). Within the custom arrangement service area, the member only has in-network access to the Blue Precision and Traditional network. The member may also be set up to have national access to the BlueCard PPO or Qualified PPO pre-deployed network outside of the custom arrangement service area (Program Code A, Delivery Method K or 2). Generally, Exchange members claims with a delivery method H should be handled the same way that claims with a Delivery Method of 56

H are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W) when the discount applies for Exchange members. Par/Host Plans will need to look at the Delivery Method (H) and Account Type Code (E or F) to identify Exchange members with access to a Blue Precision custom network and BlueCard Traditional wrap in the custom arrangement service area. The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. Please see current edits IRL2F and PRL1Q for detail on how Classification of Provider and Provider Type Availability will be required for members with access to Blue Precision custom networks. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/landingpagelevel3/703300?docId=15118 Network Availability N, Y, 3, and 4 Not valid 1 Custom Network Available (Only Used when Delivery Method = G, H or I) 2 Custom Network not Available (Only used when Delivery Method = H or I) Blank Provider Type Availability N, Y, 3, and 4 Not valid 1 Custom Network Available (Only Used when Delivery Method = G, H or I) 2 Custom Network not Available (Only used when Delivery Method = H or I) Blank Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Blue Precision Network and BlueCard Traditional network does not go to a provider in the network, but is treated by either a Qualified PPO, BlueCard PPO, or a BlueCard Traditional Provider. In these situations, the BlueCard PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: 5, S, or T 1, D, or F 3, E, or G U, V, or W *An asterisk is included for scenarios where the situation above may apply.
57

These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method H. This implies that Qualified PPO Custom and Altnet discounts will not apply for these members.
# Variables Prg m Cod e Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provide r Type Avail
Data Element F1 Serviced by Blue Precision provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard PPO provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard PPO provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network Serviced by Qualified PPO provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by Qualified PPO provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard Traditional provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard Traditional provider Blue Precision network is not available Provider specialty desired is not available in the Blue Precision network Serviced by Non-Participating provider Blue Precision network is available Provider specialty desired is not available in the Blue Precision network Serviced by Non-Participating provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network
P07 9 1 or A
D012 H X
C023 or C052 P, Q or R
P096 1 or BLANK
P097 or P171 1 or BLAN K 1
F2
*
F3
1 or A
1 , D or F 3 , E or G
5, S or T
X 1 or A H X
*
F4
1 , D or F 3 , E or G
5, S or T
1 or BLAN K 1
X 1 or A H X 1 or A H X 1 or A H X X X
*
F5
1 , D or F 3 , E or G
U, V or W 3 , E or G U, V or W 1 , D or F 3 , E or G
1 , D or F
*
F6
1 or BLAN K 1
*
F7
*
F8
1 or A
1 , D or F 3 , E or G
2 or BLAN K 2
1 or A
3, E or G
F9
1 or A
3, E or G
2 or BLAN K
58

# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prg m Cod e Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provide r Type Avail
Data Element F10 Serviced by Unsolicited provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by Unsolicited provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network
P07 9 1 or A
D012 H
C023 or C052 9
P096 1
P097 or P171 1
F11
1 or A
1 or BLAN K
59

G. Exchange PPO member with out-of-area access to Blue Precision custom network and no wrap in the custom arrangement service area. The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO members set-up to access Blue Precision (Program Code 1 or A, Delivery Method I). Within the custom arrangement service area, the member only has in-network access to Blue Precision network. The member may also be set up to have national access to the BlueCard PPO or Qualified PPO pre-deployed network outside of the custom arrangement service area (Program Code A, Delivery Method K or 2). Generally, Exchange members claims with a delivery method I should be handled the same way that claims with a Delivery Method of I are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W) when the discount applies for Exchange members. Par/Host Plans will need to look at the Delivery Method (I) and Account Type Code (E or F) to identify Exchange members with access to a Blue Precision custom network and no wrap in the custom arrangement service area. The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. Please see current edits IRL2F and PRL1Q for detail on how Classification of Provider and Provider Type Availability will be handled for members with access to Blue Precision custom networks. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/landingpagelevel3/703300?docId=15118 Network Availability N, Y, 3, and 4 Not valid 1 Custom Network Available (Only Used when Delivery Method = G, H or I) 2 Custom Network not Available (Only used when Delivery Method = H or I) Blank Provider Type Availability N, Y, 3, and 4 Not valid 1 Custom Network Available (Only Used when Delivery Method = G, H or I) 2 Custom Network not Available (Only used when Delivery Method = H or I) Blank Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the Blue Precision Network does not go to a provider in the network, but is treated by either a Qualified PPO, BlueCard PPO, or a BlueCard Traditional Provider. In these situations, the
60

BlueCard PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: 5, S, or T 1, D, or F 3, E, or G U, V, or W *An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for), Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method I. This implies that Qualified PPO Custom and Altnet discounts will not apply for these members.
# Variables Trad Contract Covers Mbrs Pgm Cod e Mthd PPO Contract Covers Mbrs Class of Provider (CP) Networ k Avail (NA) Provid er Type Avail
Data Element G1
P07 9 1 or A
D012
C023 or C052
P096
G2
*
G3
*
G4
*
G5
*
G6
*
G7
Serviced by Blue Precision provider BlueCard PPO network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard PPO provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard PPO provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network Serviced by Qualified PPO provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by Qualified PPO provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard Traditional provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by BlueCard Traditional provider
P, Q or R
1 or BLAN K 1
P097 or P171 1 or BLAN K 1
1 or A
I X
1 , D or F 3 , E or G 5 , S or T 1 , D or F 3 , E or G 5 , S or T 1 , D or F 3 , E or G U, V or W
1 or A
I X
1 or BLAN K 1
1 or A
I X
1 or A
I X
1 , D or F 3 , E or G U, V or W
1 or BLAN K 1
1 or A
1 , D or F 3 , E or G
1 or A
1 , D or F
2 or BLAN
61

# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Pgm Cod e Mthd Class of Provider (CP) Networ k Avail (NA) Provid er Type Avail
Data Element
P07 9
D012
C023 or C052
P096
*
G8
G9
G10
G11
Blue Precision network is not available Provider specialty desired is not available in the Blue Precision network Serviced by Non-Participating provider Blue Precision network is available Provider specialty desired is not available in the Blue Precision network Serviced by Non-Participating provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network Serviced by Unsolicited provider Blue Precision network is available Provider specialty desired is available in the Blue Precision network Serviced by Unsolicited provider Blue Precision network is not available Provider specialty desired is available in the Blue Precision network
3 , E or G
P097 or P171 K
1 or A
3, E or G
1 or A
3, E or G
1 or BLAN K 1
1 or A
1 or A
1 or BLAN K
62

H. Exchange PPO, Traditional, HMO, or POS member with out-of-area access to Traditional network The scenarios below provide information for Par/Host Plans on SF creation for Exchange PPO, Traditional, HMO or POS members set-up to access the Traditional network (Program Code A or 1, Delivery Method 1). Generally, Exchange members claims with a delivery method 1 should be handled the same way that claims with a Delivery Method of 1 are handled today. One difference to note is that Par/Host Plans should include new classification of provider values for Qualified PPO (U, V, W) when the discount applies for Exchange members. Network Availability Indicator and Provider Type Availability Indicators are not required for members with access to the BlueCard Traditional Network. When Delivery Method equals 1: P096 is not required P097 and P171 are not required Classification of Provider (C023 or C052) Par/Host Plans will need to review their provider contracts to determine the appropriate Classification of Provider field values for scenarios where a member that is set up to access the BlueCard Traditional Network does not go to a provider in the network, but is treated by a Qualified PPO, BlueCard PPO or a BlueCard Traditional Provider. In these situations, the Qualified PPO, BlueCard PPO or BlueCard Traditional discount may still apply. For this reason, Par/Host Plans will either classify these providers with: 5, S, or T 1, D, or F 3, E, or G U, V, or W *An asterisk is included for scenarios where the situation above may apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), Altnets (J, K, or L) and Blue Precision (P, Q, or R). Par/Host Plans will not populate these Classifications of Providers on claims with Delivery method of 1. This implies that Qualified PPO Custom, Altnet, and Blue Precision discounts will not apply for these members.
# Variables Prg m Cod e Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provider Type Avail
Data Element H1 Serviced by BlueCard Traditional provider
P07 9 A or
D012 1 X
C023 or C052 1, D or F
P096 BLANK
P097 or P171 BLANK
63

# Variables Trad Contract Covers Mbrs PPO Contract Covers Mbrs Prg m Cod e Dlvy Mthd Class of Provider (CP) Network Avail (NA) Provider Type Avail
Data Element Traditional network is available Provider specialty desired is available in the Traditional network Serviced by Qualified PPO provider Traditional network is available Provider specialty desired is available in the Traditional network Serviced by Qualified PPO provider Traditional network is not available Provider specialty desired is available in the Traditional network Serviced by BlueCard PPO provider Traditional network is available Provider specialty desired is available in the Traditional network Serviced by BlueCard PPO provider Traditional network is not available Provider specialty desired is available in the Traditional network Serviced by Non-Participating provider Traditional network is available Provider specialty desired is not available in the Traditional network Serviced by Non-Participating provider Traditional network is not available Provider specialty desired is available in the Traditional network Serviced by Unsolicited provider Traditional network is available Provider specialty desired is not available in the Traditional network Serviced by Unsolicited provider Traditional network is not available Provider specialty desired is not available in the Traditional network
P07 9 1
D012
C023 or C052
P096
P097 or P171
H2
*
H3
A or 1
1 X
*
H4
A or 1
1 X
1, D or F U, V, or W 3, E or G 1, D or F U, V, or W 3, E or G 1, D or F 5, S, or T 3, E or G 1, D or F 5, S, or T 3, E or G 3, E or G
BLANK
BLANK
BLANK
BLANK
*
H5
A or 1
1 X
BLANK
BLANK
*
H6
A or 1
1 X 1
BLANK
BLANK
A or 1
BLANK
BLANK
H7
A or 1
3, E or G
BLANK
BLANK
H8
A or 1
BLANK
BLANK
H9
A or 1
BLANK
BLANK
64

Control/Home Plan Benefit Scenarios
The Control/Home Plan benefit scenarios below will assist Control/Home Plans in ensuring that their systems are set up to recognize Submission Format values on Exchange member claims and accurately apply benefits. The scenarios have been created for Exchange members with the following types of products: A. Exchange PPO member with out-of-area access to Qualified PPO network. B. Exchange PPO member with out-of-area access to BlueCard PPO network. C. Exchange PPO member with out-of-area access to Qualified PPO Custom network. D. Exchange PPO member with out-of-area access to AltNet network. E. Exchange PPO member with out-of-area access to Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. F. Exchange PPO member with out-of-area access to Blue Precision custom network and Traditional wrap in the custom arrangement service area. G. Exchange PPO member with out-of-area access to Blue Precision custom network and no wrap in the custom arrangement service area. H. Exchange PPO, Traditional, HMO, or POS member with out-of-area access to Traditional network. Legend of ITS field values: The fields in blue are new values for BlueCard for Exchanges (ITS Release 13.0) and are subject to change based on final functional specifications (completed Fall 2012). Program Codes A = Inter-Plan Business 1 = Custom Delivery Methods 1 = Traditional 2 = BlueCard PPO 3 = Point of Service (not in scenarios) 5 = HMO (not in scenarios) J = AltNet Networks G = Custom Network with PPO Wrap H = Custom Network with Traditional Wrap I = Custom Network with No Wrap K = Qualified PPO L = Qualified PPO Custom Classification of Provider 1 = Participating Provider 3 = Non-Participating Provider 5 = PPO 9 = Unsolicited Provider D = Veterans Administration ProviderParticipating E = Veterans Administration Provider- NonParticipating F = Military Facility- Participating G = Military Facility- Non-Participating J= AltNet Network Provider K = Veterans Administration- AltNet L = Military Facility- AltNet P = Custom Network Provider Q = Veterans Administration Provider Blue 65

Precision R = Military Facility Blue Precision S = Veterans Administration Provider PPO T = Military Facility- PPO U = Qualified PPO Provider V= Veterans Administration Exchange Qualified Provider W= Military Facility Exchange Qualified Provider X = Qualified PPO Custom Provider Y= Veterans Administration Exchange Qualified Custom Provider Z= Military Facility Exchange Qualified Custom Provider NOTE: Program Code 8 is not included in these scenarios because NASCO to NASCO claims do not use the Submission Format.
66

A. Exchange PPO member with out-of-area access to the Qualified PPO network. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the Qualified PPO pre-deployed network (Program Code A or 1, Delivery Method K). These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Claims with Delivery Method K will not be received with these Classification of Provider values. NOTE: Control/Home Plan systems will need to recognize BlueCard PPO as in-network when a Qualified PPO Network is not available (see scenario A4).
# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052
Network Avail Provider Type (NA) Avail

P096 (required when C023 U, V or W) P097 or P171 (required when C023U, V or W and NA N) Y or BLANK Y N
Hold Harmless
H073
Benefit Level
A1 A2 A3
A OR 1 A OR 1 A OR 1
K K K
U, V or W 5 , S or T
Y, N, or BLANK Y Y
HH HH HH
In-network Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available In-Network In areas where no Qualified PPO Network is available, BlueCard PPO is considered in-network Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network
5 , S or T
A4
A OR 1
5 , S or T
Y, N, or BLANK
HH
A5 A6
A OR 1 A OR 1
K K
1, D or F 1, D or F
Y Y
Y N
HH HH
A7
1, D or F
Y, N, or BLANK
HH
A8
K K
3, E or G 3, E or G
A9
HH may or may not apply HH may or may not apply
Depends on Control/Home Plan Possibly In-network because no
67

# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 U, V or W) P097 or P171 (required when C023U, V or W and NA N)
Hold Harmless
H073
Benefit Level
A10
3, E or G
Y, N, or BLANK
HH may or may not apply HH HH
provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available
A11 A12
K K
X, Y, or Z X, Y, or Z
Y Y
Y N
A13
A OR 1 A OR 1
X, Y, or Z 9
Y, N, or BLANK
HH
A14
HH may or may not apply
A15
A OR 1
68

B. Exchange PPO member with out-of-area access to BlueCard PPO network. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the BlueCard PPO network (Program Code A or 1, Delivery Method 2). These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Claims with Delivery Method 2 will not be received with these Classification of Provider values.
# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 5, S, or T) Y, N, or BLANK Y Y P097 or P171 (required when C023 5, S, or T and NA N) Y or BLANK Y N
Hold Harmless
H073
Benefit Level
B1 B2 B3
2 2 2
5 , S or T U, V or W U, V or W
HH HH HH
In-network Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network
B4
U, V or W 1, D or F 1, D or F
N or BLANK
HH
B5 B6
2 2
Y Y
Y N
HH HH
B7
1, D or F
N or BLANK
HH
B8
2 2
3, E or G 3, E or G
B9
Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan
B10
A OR 1
3, E or G
N or BLANK
HH may or may
69

# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 5, S, or T) P097 or P171 (required when C023 5, S, or T and NA N)
Hold Harmless
H073
Benefit Level
not apply
B11 B12
A OR 1 A OR 1
2 2
X, Y, or Z Y X, Y, or Z Y
Y N
HH HH
Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available
B13
A OR 1 A OR 1
X, Y, or Z N
N or BLANK
HH
B14
B15
A OR 1
70

C. Exchange PPO member with out-of-area access to Qualified PPO Custom network. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the Qualified PPO custom network (Program Code 1 or A, Delivery Method L). The member may also be set up to have national access to the BlueCard PPO, Qualified PPO network, or Bluecard Traditional network outside of the custom arrangement service area (Program Code A, Delivery Method K,2, or 1). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H may apply. These scenarios do not include Classification of Provider for Altnets (J, K, or L) and Blue Precision (P, Q, or R). Claims with Delivery Method L will not be received with these Classification of Provider values.
# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 X, Y, or Z) P097 or P171 (required when C023 X, Y, or Z and NA N) Y or BLANK Y N
Hold Harmless
H073
Benefit Level
C1 C2 C3
A or 1 A or 1 A or 1
L L L
X, Y, or Z U, V or W U, V or W
Y, N, or BLANK Y Y
HH HH HH
In-network Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network
C4
U, V or W
Y, N, or BLANK
HH
C5 C6
L L
5 , S or T 5 , S or T
Y Y
Y N
HH HH
C7
A or 1 A or 1
5 , S or T
Y, N, or BLANK
HH
C8
1, D or F
71

# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 X, Y, or Z) P097 or P171 (required when C023 X, Y, or Z and NA N) N
Hold Harmless
H073
Benefit Level
C9
A or 1
1, D or F
Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available
C10
1, D or F
Y, N, or BLANK
HH may or may not apply HH HH
C11 C12
L L
3, E or G 3, E or G
Y Y
Y N
C13
A or 1 A or 1
3, E or G
Y, N, or BLANK
HH
C14
C15
A or 1
72

D. Exchange PPO Custom member with out-of-area access to AltNet network. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the AltNet network (Program Code 1 or A, Delivery Method J). The member may also be set up to have national access to the BlueCard PPO, Qualified PPO network, or Bluecard Traditional network outside of the custom arrangement service area (Program Code A, Delivery Method K,2, or 1). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H may apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z) and Blue Precision (P, Q, or R). Claims with Delivery Method J will not be received with these Classification of Provider values.
# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 J, K, or L) P097 or P171 (required when C023 J, K, or L and NA N) Y, N, or BLANK Y N
Hold Harmless
H073
Benefit Level
D1 D2 D3
J J J
J, K, or L 5, S or T 5, S or T
Y, N, or BLANK Y Y
HH HH HH
In-network Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Depends on Control/Home Plan
D4
5, S or T
N or BLANK
HH
D5 D6
J J
U, V or W U, V or W
Y Y
Y N
HH HH
D7
A or 1 A or 1 A or
U, V or W 1, D or F 1, D or F
N or BLANK
HH
D8 D9
J J
Y Y
Y N
HH HH
73

# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (required when C023 J, K, or L) P097 or P171 (required when C023 J, K, or L and NA N)
Hold Harmless
H073
Benefit Level
1
Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network
D10
1, D or F
N or BLANK
HH
D11
J J
3, E or G 3, E or G
D12
Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Possibly In-network because no provider of the specialty desired was available Depends on Control/Home Plan Possibly In-network because no network was available
D13
A or 1 A or 1
3, E or G
N or BLANK
D14
D15
A or 1
74

E. Exchange PPO member with out-of-area access to Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the Blue Precision network (Program Code 1 or A, Delivery Method G). Within the custom arrangement service area, the member only has in-network access to the Blue Precision Network and BlueCard PPO Network. The member may also be set up to have national access to the BlueCard PPO, Qualified PPO network, or Bluecard Traditional network outside of the custom arrangement service area (Program Code A, Delivery Method K,2, or 1). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Claims with Delivery Method G will not be received with these Classification of Provider values. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/bluecard/attachments/na_net_mngt/Network_Options_Custom_N et_Imp_Guide_01.2012.pdf
# Prgm Code P079 E1 E2 1 or A 1 or A Dlvy Mthd D012 G G Class of Provider (CP) C023 or C052 P, Q or R 5, S or T Network Avail (NA) P096 1 1 Provider Type Avail P097 or P171 1 or BLANK 1
Hold Harmless
Benefit Level
HH HH
In-network (highest level of benefits) In-network (lower level benefits) Blue Precision Network was available and provider specialty was available In-network (lower level benefits) Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network In-network (lower level benefits) Blue Precision Network wasnt available, but BlueCard PPO was available Out-of-network Blue Precision Network was available and provider specialty was available
E3
1 or A
5, S or T
HH
E4
1 or A
5, S or T
3 or BLANK
HH
E5
1 or A
U, V or W
HH
75

# Prgm Code P079 E6 1 or A Dlvy Mthd D012 G Class of Provider (CP) C023 or C052 U, V or W Network Avail (NA) P096 1 Provider Type Avail P097 or P171 3
Hold Harmless
Benefit Level
HH
Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available, but BlueCard PPO was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available, but BlueCard PPO was available Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available, but BlueCard PPO was available
E7
1 or A
U, V or W
3, 4, or BLANK
HH
E8
1 or A
U, V or W
4 or BLANK
HH
E9
1 or A
1, D or F
HH
E10
1 or A
1, D or F
HH
E11
1 or A
1, D or F
3, 4, or BLANK
HH
E12
1 or A
1, D or F
4 or BLANK
HH
E13
1 or A
3, E or G
E14
1 or A
3, E or G
E15
1 or A
3, E or G
3, 4, or BLANK
76

# Prgm Code P079 E16 1 or A Dlvy Mthd D012 G Class of Provider (CP) C023 or C052 3, E or G Network Avail (NA) P096 4 Provider Type Avail P097 or P171 4 or BLANK
Hold Harmless
Benefit Level
Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available, but BlueCard PPO was available Depends on Control/Home Plan Blue Precision Network wasnt available, but BlueCard PPO was available
E17
1 or A
E18
1 or A
E19
1 or A
77

F. Exchange PPO member with out-of-area access to Blue Precision custom network and Traditional wrap in the custom arrangement service area. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access the Blue Precision network (Program Code 1 or A, Delivery Method H). Within the custom arrangement service area, the member only has in-network access to the Blue Precision and Traditional network. The member may also be set up to have national access to the BlueCard PPO, Qualified PPO network, or Bluecard Traditional network outside of the custom arrangement service area (Program Code A, Delivery Method K,2, or 1). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A, B, or H would apply. These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Claims with Delivery Method H will not be received with these Classification of Provider values. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/bluecard/attachments/na_net_mngt/Network_Options_Custom_N et_Imp_Guide_01.2012.pdf
# Prgm Code Dlvy Mthd Class of Provider (CP) C023 or C052 P, Q or R 5, S or T Network Avail (NA) P096 1 1 Provider Type Avail
Hold Harmless
H073 HH HH
Benefit Level
P079 F1 F2 1 or A 1 or A
D012 H H
P097 or P171 1 or BLANK 1
In-network Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available Out-of-network Blue Precision Network was available and provider specialty was available
F3
1 or A
5, S or T
HH
F4
1 or A
5, S or T
2 or BLANK
HH
F5
1 or A
U, V or W
HH
78

# Prgm Code Dlvy Mthd Class of Provider (CP) C023 or C052 U, V or W Network Avail (NA) P096 1 Provider Type Avail
Hold Harmless
H073 HH
Benefit Level
P079 F6 1 or A
D012 H
P097 or P171 2
Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available In-network (lower level benefits) In-network (lower level benefits) In-network (lower level benefits) Blue Precision Network wasnt available Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Blue Precision Network wasnt available
F7
1 or A
U, V or W
2 or BLANK
HH
F8 F9 F10
1 or A 1 or A 1 or A
H H H
1, D or F 1, D or F 1, D or F
1 1 2
1 2 2 or BLANK
HH HH HH
F11
1 or A
3, E or G
F12
1 or A
3, E or G
F13
1 or A
3, E or G
2 or BLANK
F14
1 or A
F15
1 or A
79

G. Exchange PPO member with out-of-area access to Blue Precision custom network and no wrap in the custom arrangement service area. The scenarios below provide information for Control/Home Plans on the handling of claims received for Exchange PPO members set-up to access Blue Precision (Program Code 1 or A, Delivery Method I). Within the custom arrangement service area, the member only has innetwork access to Blue Precision network. The member may also be set up to have national access to the BlueCard PPO, Qualified PPO network, or Bluecard Traditional network outside of the custom arrangement service area (Program Code A, Delivery Method K,2, or 1). The scenarios below apply when the member is in the custom arrangement service area. When the member is outside of the custom arrangement service area, the scenarios in section A or B, or H would apply. These scenarios do not include Classification of Provider for), Qualified PPO Custom (X, Y, or Z), or Altnets (J, K, or L). Claims with Delivery Method I will not be received with these Classification of Provider values. Custom Networks Implementation Guide http://bluewebportal.bcbs.com/bluecard/attachments/na_net_mngt/Network_Options_Custom_N et_Imp_Guide_01.2012.pdf
# Pgm Cod e P07 9 1 or A 1 or A Mthd Class of Provider (CP) C023 or C052 P, Q or R 5, S or T Network Avail (NA) P096 1 1 Provider Type Avail P097 or P171 1 or BLANK 1
Hold Harmless
H073 HH HH
Benefit Level
D012 I I
G1 G2
In-network Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Blue Precision Network was available and provider specialty was available
G3
1 or A
5, S or T
HH
G4
1 or A
5, S or T
2 or BLANK
HH
G5
1 or A
U, V or W
HH
80

# Pgm Cod e P07 9 1 or A Mthd Class of Provider (CP) C023 or C052 U, V or W Network Avail (NA) P096 1 Provider Type Avail P097 or P171 2
Hold Harmless
H073 HH
Benefit Level
D012 I
G6
Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Possibly In-network because no network was available Out-of-network Blue Precision Network was available and provider specialty was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Possibly In-network because no network was available Depends on Control/Home Plan Blue Precision Network was available, but a provider of the desired specialty was not available in the Blue Precision network Depends on Control/Home Plan Possibly In-network because no
G7
1 or A
U, V or W
2 or BLANK
HH
G8
1 or A
1, D or F
HH
G9 1 or A I 1, D or F
HH
G10 1 or A G11 1 or A I 1, D or F
2 or BLANK
HH
3, E or G
G12
1 or A
3, E or G
G13
1 or A
3, E or G
2 or BLANK
G14
1 or A
G15
1 or A
81

# Pgm Cod e P07 9 Mthd Class of Provider (CP) C023 or C052 Network Avail (NA) P096 Provider Type Avail P097 or P171
Hold Harmless
H073
Benefit Level
D012
network was available
82

H. Exchange PPO, Traditional, HMO, or POS member with out-of-area access to Traditional network. The scenarios below provide information for Control Control/Home Plans on the handling of claims received for Exchange PPO, Traditional, HMO or POS members set-up to access the Traditional network (Program Code A or 1, Delivery Method 1). These scenarios do not include Classification of Provider for Qualified PPO Custom (X, Y, or Z), Altnets (J, K, or L) and Blue Precision (P, Q, or R). Claims with Delivery Method 1 will not be received with these Classification of Provider values.
# Prgm Code
P079
Dlvy Mthd
D012
Class of Provider
C023 or C052

P096 (not required when Delivery Method = 1) BLANK BLANK BLANK BLANK P097 or P171 (not required when Delivery Method = 1) BLANK BLANK BLANK BLANK
Hold Harmless
H073
Benefit Level
H1 H2 H3 H4
A A A A A A
1 1 1 1 1 1
1, D or F 5, S, or T U, V, W 3, E or G 9 9
H5
BLANK
BLANK
H6
BLANK
BLANK
HH HH HH HH may or may not apply HH may or may not apply HH may or may not apply
Out-of-network Out-of-network Out-of-network Out-of-network
Out-of-network
Out-of-network
83

Plan Profiles
Plans create Plan Profiles with a unique, Plan-specific alpha prefix for Exchange members. The alpha prefix can be obtained through BlueWeb at: http://blueweb.bcbs.com/blueweb/Leaf?docId=13484. A Plan profile with a unique, Plan-specific alpha prefix will need to be created for the following types of Exchange members: Individual Exchange PPO members o Separate profiles needed for delivery methods 2, G, H, I, J, K & L SHOP Exchange PPO Members o Separate profiles needed for delivery methods 2, G, H, I, J, K & L Individual Exchange HMO, POS, and Traditional members SHOP Exchange HMO, POS, and Traditional members
Plans will be notified of new Exchange product offerings through the distribution of Plan Profile standard rules. The Standard Plan Profile Mass Distribution is distributed every Tuesday to the Plans. For purposes of this document, Standard Rule Plan Profiles represents the processing arrangement applicable to all Plans. Standard Rules establish an approved set of functions for all BlueCard or Medicare Advantage claims processing. Custom Rule Plan Profiles represent individual specialized agreements between two Plans. Values included in the following Plan Profile examples will be valid with ITS Release 13.0. Examples of Standard Plan Profiles have been created and included in this section for the following types of members: Exchange PPO member with out-of-area access to Qualified PPO network. Exchange PPO member with out-of-area access to BlueCard PPO network. Exchange member with out-of-area access to Traditional network. (The local exchange product may be any local Blue product) Examples of Custom Plan Profiles have been created and included in this section for the following types of members: Exchange PPO member with out-of-area access to Qualified PPO Custom network. Exchange PPO member with out-of-area access to AltNet network. Exchange PPO member with out-of-area access to Blue Precision networks Off Exchange National Account members with access to a Qualified PPO Custom network
84

Setting up Plan Profiles 1. The Effective Start Date could be earlier than 1/1/2014; however, the Receipt/Incurred Start Date should be set to 01/01/2014. 2. The rule should be Incurred Date based (meaning that the rule would apply based on the first date of service as opposed to the date the Local Plan receives the claim).
3. The Effective End Date and Receipt/Incurred End Dates should be set to 99/99/9999. Exchange Plan Profile Standard Rule Examples A. Exchange PPO member with out-of-area access to the National Qualified Exchange PPO network. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = A Claim Development = Y Managed Care indicator = 0 Delivery Method = K Product Type = 5 National Out of Area indicator = 2 Account Type =E or F (individual or SHOP) Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank 85

B. Exchange PPO member with out-of-area access to BlueCard PPO network. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = A Claim Development = Y Managed Care indicator = 0 Delivery Method = 2 Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank C. Exchange member with out-of-area access to Traditional network. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = A 86

Claim Development = Y Managed Care indicator = 0 Delivery Method = 1 Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank
On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank Exchange Plan Profile Custom Rule Examples D. Exchange PPO member with out-of-area access to Qualified PPO Custom network. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = L Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): 87

Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank
E. Exchange PPO member with out-of-area access to Blue Precision custom network and BlueCard PPO wrap in the custom arrangement service area. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = A or 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = G Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1
88

Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank
F. Exchange PPO member with out-of-area access to Blue Precision custom network and Traditional wrap in the custom arrangement service area. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = H Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank G. Exchange PPO member with out-of-area access to Blue Precision custom network and no wrap in the custom arrangement service area. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y 89

Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = I Product Type = 5 National Out of Area indicator = 2 Account Type = E or F Custom Primary and Secondary Networks = blank
On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank H. Exchange PPO member with out-of-area access to AltNet network. On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = J Product Type = 5 National Out of Area indicator = 2 Account Type = E or F 90

Custom Primary and Secondary Networks = blank
On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank I. Off Exchange (not SHOP) National Account with access to a Qualified PPO Custom network On the Submission Screen (CS09): Submission Process = Y Submission Edit = Y Provider Data = Y Pricing Data = Y Adjustment Edit Indicator= Y UPF Pricing Edit = 1 Program Code = 1 Claim Development = Y Managed Care indicator = 0 Delivery Method = L Product Type = 5 National Out of Area indicator = 2 Account Type = A, B, or C, Custom Primary and Secondary Networks = blank On the Disposition screen (CS10): Plan Payer = Defaults to 1 Plan Payer Qualifier = blank SCDF Type = 1 Additional Statistical Data = 0 1099 Generation = 1 EOB Generation = 2 Access Fee Code = 1 91

Resubmit DF Indicator = Y Central Financial Agency Code = 1 Control Plan CFA Account Code will be determined by each Control Plan, dependent on how they have their arrangement set up with Mellon Bank. Administrative Expense Allowance (AEA) Code = 1 Non-Standard AEA Amount field = blank
92
VERSION 1.0 January 10, 2013 CHAPTER 4: ADDITIONAL INFORMATION

This chapter provides additional information on specific Inter-Plan business operations that will be pertinent to the successful implementation of BlueCard for Public Exchange Products; however, these business procedures have not been altered from current BlueCard business practices.
Inter-Plan Fees
Par/Host Plans will receive an administrative expense allowances (AEAs) for Inter-Plan Programs claims unless Plans have agreed to a negotiated reimbursement arrangement. Inter-Plan Fees for Individual Business In June 2012, the Board approved a new $12 per claim Inter-Plan Fee, and related Policy changes to support Blue leadership in the under-65 individual retail market. This new fixed rate will be valid for individual Exchange business and non-Exchange individual business sold with an effective date on or after January 1, 2014. The $12 rate is a replacement for the standard BlueCard fees, including the access fees and the (AEAs). Claims for individual business are subject to Inter-Plan fees only when members travel or commute outside the service area of their Control/Home Plan. For certain states with guaranteed renewable coverage, individuals may reside outside of the Control/Home Plans service area and be subject to the new fee. The new single flat fee will apply to all individual business traveler claims regardless of the type of network accessed by the member and BlueCard Program Product Type value assigned for processing. Claims for individual non-travelers will continue to enter into a Control/Home Plans local claims system which bypass Inter-Plan fees altogether. The $12 rate will be applied to all Plan Profile standard (STX) rules for individual account types. See IP Policy IP Policy 3.08, Par/Host Licensee Access Fees and IP 3.09, Par/Host Licensee Expense Reimbursement for additional information.
Inter-Plan Fees for Group Business Group Inter-Plan fees may be charged in accordance with the provisions of IP Policy 3.08Par/Host Licensee Access Fees and IP 3.09- Par/Host Licensee Expense Reimbursement. Claims for SHOP Exchange business will be processed under existing Inter-Plan fee arrangements and
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not subject to the new single flat rate per claim unless agreed to between the Control/Home and Par/Host Plan prior to the effective date of the group.
Negotiating Fees Plans will be able to negotiate fees under the same rules as they are able to for other inter-Plan business. Plans choosing to negotiate something lower than the standard rate or waive fees as part of a reciprocity arrangement will be able to do so using custom Plan Profile rules. Please contact Ken Matuszak (Ken.Matuszak@bcbsa.com) with questions related to Inter-Plan fees for Exchange members. IPP Financial Policy, Pricing Administration and Financial Audits Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/708050?docId=16822
Licensee Desk Level Audits (LDLA)

Licensee Desk Level Audits must be performed in accordance with Inter-Plan policies. Beginning January 1, 2014, Exchange member claims with the following Program Codes and Delivery methods will be included in the regular LDLA system sample and process: Program Codes: 1, A, or 8, and Delivery Methods 1, 2, 3, 5, G, H, I, J, K or L
Please contact Chris Oh (Christopher.Oh@bcbsa.com) with questions related to LDLA for Exchange members. Licensee Desk Level Audit Overview and Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/708100?docId=7292
Appeals and Grievances

Blue Plans are responsible for handling all member and provider appeals and grievances in accordance with Inter-Plan Policies. Please contact Cathy Reice (Catherine.Reice@bcbsa.com) with questions related to appeals and grievances for Exchange members. Claim Appeal Process Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/704100?docId=20445 Blue Squared Licensee Requirement Manual: 94

http://bluewebportal.bcbs.com/landingpagelevel3/703200?docId=17504#0.0
Network Reporting Services

The purpose of the Network Reporting Services component of the National Database Integration (NDI) is to enhance the request management process for Geographic Accessibility, Disruption Analysis, Product Area Match, and Provider Count Reports. As is done today for BlueCard PPO networks and other custom networks, Plans will have the ability to request Geo Access Reports for the National Exchange Qualified PPO Network and Qualified Exchange PPO Custom networks. Contingent upon Plan submission of new Qualified Exchange PPO provider networks by June 1 2013, and data verification, Plans may begin requesting Geo Access Reports for members with access to the National Qualified PPO network on September 1, 2013. New fields, including networks and account types, will be added into the network report request form in order to extract accurate data and measure the success of report results. Please contact Angela Harris (Angela.Harris@bcbsa.com) with questions about Network Reporting for Exchange business. Network Reporting Services NDI Log-In Page: http://nrs.bcbs.com/NRSWeb/public/jsp/login.jsp IPO Network Reporting Services Reference Page : http://bluewebportal.bcbs.com/landingpagelevel3/703150?docId=13420
Inter-Plan Programs Performance/ Scorecard

The Inter-Plan Programs (IPP) Performance Scorecard assesses operational and service performance of all inter-Plan program claims. Current Inter-Plan policies require information to be collected and reported quarterly. Beginning January 1, 2014, Exchange member claims with the following Program Codes and Delivery methods will be included in the IPP Performance Scorecard process: Program Codes: 1, A, or 8, and Delivery Methods 1, 2, 3, 5, G, H, I, J, K or L
Exchange member claims will be combined with other Inter-Plan business for IPP Scorecard reporting. A business segregation will be available for Plans to track and monitor this business in the Transactional and Completed Claim dashboards in the Inter-Plan Data Solutions application (IPDS).
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Please contact Brenda Muehlbauer (brenda.muehlbauer@bcbsa.com) with questions related to IPP Performance.
Claims Handling for Claims Received During the Exchange Individual Grace Period
NOTE: The below proposed approach to address claims handling during the grace period for individuals eligible for subsidies will be presented during the Q1 2013 governance cycle for approval. Per the Exchange final rule, there is a three month grace period for individuals eligible for subsidies. The individual is required to pay premium for the first month of the grace period and the members Plan is required to pay claims received in the first month. Per the regulations, in the second and third months of the grace period, Plans: May pend claims to await premium payments, Must notify HHS of the non-payment of premium, and. Must notify providers of the possibility for denied claims. Proposed Control/Home Plan Responsibilities Upon receipt of a claim filed during the second and third months of the Exchange individual grace period, Control/Home Plans must not deny claim. Control/Home Plans may pay the claim or may pend the claim by either: Applying a hard pend with the new unique informational only DF message code and sending an info message in BlueSquared. o The info message will be automated by the ITS and BlueSquared systems upon the application of the new DF message code. o The Control/Home Plan must update their BlueExchange claim status transaction response to indicate the claim is pended and not denied. o The Control/Home Plan must adjust the claim using the new unique adjustment reason code in order to finalize the claim to pay or deny once the grace period ends or member pays premium. o The adjustment will be carved out of the end to end claims experience measure in the Inter-Plan performance Scorecard. Pending the claim by keeping it open on their local and formats database and sending an info message in BlueSquared within 14 calendar days of receipt of the Submission Format. o The info message will trigger the SF to be excluded from default claim resolution. o The Control/Home Plan must adjudicate the claim to pay or deny once the grace period ends or the member pays premium
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Proposed Par/Host Plans Responsibilities During the second and third months of the Exchange individual grace period, Par/Host Plans should: Send standard messaging to the local provider upon receipt of the DF message code (hard pend) or info message indicating that the claim is being pended.
Provider Notification Language NOTE: The proposed standard messing to local providers will be presented during the Q1 2013 governance cycle for approval.
To ensure that providers receive consistent communication in these situations, BCBSA has created standard messaging for providers. See Exhibit 4: Provider Education Material for the sample provider letter and electronic notification language for the Exchange Individual Grace Period. Par/Host Plan Assistance with State or Federal Audits Par/Host Plans should assist the Control/Home Plan with state or federal audits within the timeframes required by applicable law or, if there is no timeframe specified by law, as mutually agreed upon by Licensees. The Control/Home Plan is responsible for funding the costs of the audits. NOTE: Default Claims Resolution functionality will not apply if the Control/Home Plan denies the claim with the new DF Message Code [TBD- ITS Release 13.5] within 60 calendar days of receipt of the Submission Format from the Par/Host Plan. The default claims functionality will not kick in due to the use of the new informational DF Message Code. Inter-Plan Performance Scorecard Overview and Reference Page: http://bluewebportal.bcbs.com//landingpagelevel3/701400?docId=16973#0.0
Consumer Transparency Reporting for Exchange Business

Under the Affordable Care Act of 2010, Exchanges will require Plans seeking certification to report on and disclose information on enrollment, claim, and financial data to various entities. These entities, the types of data, and the inter-Plan approach for each are described below. NOTE: The information provided below is based on information available to date (PPACA; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers, Final Rule -156.220 Transparency in coverage) and may be reconsidered when more information on transparency reporting is made available or regulations are published. QHPs are required to report transparency information to the following entities: 97

The State or Federal Exchange, as applicable The U.S. Health and Human Services Secretary The applicable State Insurance Commissioner The Public
The Types of Data Reported and the Inter-Plan Approach 1. Claims payment policies and practices Control/Home Plans may leverage the SF Pricing Methods and Rules, SF Message Codes, SF provider data, and/or SF Adjustment Reason Codes on BlueCard claims, and the NASCO equivalents for NASCO Par claims. 2. Periodic financial disclosures Periodic Financial Disclosure information for inter-Plan business is addressed in the Disclosures section of the Implementation Guide. 3. Data on enrollment Control/Home Plans have information on enrollment for their members. 4. Data on disenrollment Control/Home Plans have information on disenrollment for their members. 5. Data on the number of claims that are denied Control/Home Plans have information on benefit denials for their members claims. 6. Data on rating practices Control/Home Plans have information on rating practices for their members policies. 7. Information on cost-sharing and payments with respect to any out-of-network coverage Control/Home Plans may leverage the SF price, SF Pricing Methods and Rules, SF Message Codes, SF provider data, and/or SF Adjustment Reason Codes on BlueCard claims, and the NASCO equivalents for NASCO Par claims. 8. Information on enrollee and participant rights under this title Control/Home Plans handle enrollee rights for their members. 9. Other information as determined appropriate by the Secretary BCBSA and Plans will review inter-Plan impacts as additional information is published. Please contact Christopher Oh (christopher.oh@bcbsa.com) with questions related to Reporting and Data Analytics for Exchange members.
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Risk Adjustment
Federal regulations require that, effective 2014, Qualified Health Plans participate in riskadjustment for individual and small group markets. Par/Host Plans should ensure participating providers respond to requests received from the medical record retrieval vendor, or the Par/Host Licensee on behalf of the medical record retrieval vendor, in support of Risk Adjustment, and other government related programs, within the requested timeframe. Risk adjustment revenues are expected to be material and will be key to success in the individual and small group markets. Please contact Amy Rogala (Amy.Rogala@bcbsa.com) with questions related to risk adjustment for Exchange business. Risk Adjustment Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/705200?docId=24840
BlueCard Worldwide
Control/Home Licensees and Foreign Licensees are required to participate in the BlueCard Worldwide medical assistance services core program. This component includes inpatient, outpatient, and professional provider networks, medical assistance services and Claims support services outside the United States, Puerto Rico, and the U. S. Virgin Islands. Control/Home Licensees and Foreign Licensees are required to utilize BlueCard Worldwide if additional services, as referenced in the BlueCard Worldwide Chapter of the Inter-Plan Programs Manual, are covered in the Control/Home Licensees Member or account contract.
Blue Distinction
Par/Host Plans participating in the Blue Distinction Centers Program must comply in accordance with Inter-Plan Policies and the Blue Distinction Implementation Guide. The Blue Distinction Center designation will be displayed on the Blue National Doctor and Hospital Provider Finder for Qualified PPO networks. Please contact Patty Yard (Patty.Yard@bcbsa.com) with questions related to Blue Distinction. Blue Distinction Reference Page: http://bluewebportal.bcbs.com/landingpagelevel3/402050?docId=23269
Pre-Certification and Eligibility Line
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Plans are responsible for handling all eligibility and pre-certification/pre-authorization inquiries in accordance with Inter-Plan policies. Please contact Cathy Reice (Catherine.Reice@bcbsa.com) with questions related to BlueCard Eligibility.
SHOP Exchange Enrollment

Per the federal Exchange regulations, published on March 15, 2012, small employers may either enroll members on the Exchange where the employer has its principle business address or enroll members on Exchanges where employees have their primary worksites. In Q3 2012, recommended changes to policy were approved to ensure inter-Plan Policy aligns with how consumers may enroll on SHOP Exchanges. A small employer may enroll either exclusively with the Blue Plan licensed where company has its principal business address or with the Blue Plan(s) licensed where employees primary worksites are located. Additionally, a Blue Plans contacted by an employer that does not have its principal business address in the Plans service area should contact the Blue Plan in the service area where the employer has its principal business address within seven calendar days by sending an email to the National Account Executive with the following information: Employers Name Employers principal business address Employees primary worksite address Number of employees at the primary worksite located within the contacted Licensees service area.
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VERSION 1.0 January 10, 2013 CHAPTER 5: Exhibits

Exhibit 1: Plan Implementation Checklist
The checklist below should be used by Plans implementing or are in the process of implementing BlueCard for Exchanges to ensure the steps necessary have been or are being taken to complete the implementation process. Plans should complete each implementation step applicable to their Plan Exchange Participation Level: BlueCard For Public Exchange Products- PPO or EPO: These steps apply to only Blue Plans that intend to offer a PPO and/or EPO product. Plans who intend to offer PPO and/or EPO products on Exchange should complete these steps (even if offering other products). BlueCard For Public Exchange Products- Not Offering PPO or EPO: These steps apply to Blue Plans that are not offering a PPO or EPO product on Exchanges, but offering products other than PPO or EPO. BlueCard For Public Exchange Products- Not Offering Any Public Exchange Products: These steps apply to only Blue Plans that do not intend to offer products on Exchanges.
PPO or EPO
Not Offering PPO or EPO
Not Offering any Exchange Products
Implementation Step
Recommended Completion Date

*Required Date
X X X X
Plans began review of provider contracts for networks accessed by Exchange PPO (or EPO) members. Plan began making local system changes for Par/Host pricing and Control/Home benefit application. Plan made decisions on Exchange products and network access to prepare to complete third quarter 2012 exchange survey. Plan requested new network and product ID codes for new Exchange PPO network(s). Plan requested new product ID codes if using current BlueCard PPO network or custom networks already submitted for Exchange PPO members.
3/15/12
8/1/12
9/1/12
1/1/13
1/1/13
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PPO or EPO Not Offering PPO or EPO Not Offering any Exchange Products Implementation Step Recommended Completion Date
*Required Date
X X X X X X X X X X X X
X X X
If Plan will not offer an Exchange PPO (or EPO) product in 2014, the Plan sent an email to Bluecardforexchanges@bcbsa.com indicating so. Plan began to submit participating Exchange PPO provider data and Blue Physician Recognition data to BCBSA. Plan began to verify accurate submission of Physician/PCP Status Code Field in BlueCard PPO, new Exchange PPO, Altnet, & Blue Precision PDF files. Plan made the decision that it will participate on the Individual Exchange Plan made the decision that it will participate on the SHOP Exchange Plan completed set up for Print-onDemand directories. Plan notified BCBSA of any special Exchange marketing material requirements related to provider directories. Plan received requested network and product IDs.
1/1/13
1/1/13
1/1/13
1/1/13 1/1/13 2/1/13 2/1/13
2/1/13 3/1/13
Plan applied to be certified as a QHP by the state-run or federally- facilitated Exchange. Plan completed survey to determine inclusion in National Exchange Qualified PPO Network. Plan began to set-up Plan Profiles for Exchange products. Plan successfully transmitted a test PDF file for Exchange PPO provider data. Plan received network composition reports and signed-off on accuracy of new network data submitted. Plan notified BCBSA of any Inter-Plan Exchange compliance impacts.
4/1/13
4/15/13 4/15/13 5/1/13
5/1/13
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*Required Date
X X X X X X X X X X X X X X X X X X
Plan completed submitting participating Exchange PPO provider data and Blue Physician Recognition data to BCBSA. Plan completed any process changes for network alerts. Plan prepared to complete Global Certification for ITS Release 13.5. Plan submitted pricing methods and rule combination forms for new Exchange PPO networks. Plan prepared to submit cost data to BCBSA for new Exchange PPO networks. Plan submitted data for Physician Quality Measurement. Plan completed steps to successfully connect with the Exchange (e.g. for enrollment) Plan made operational changes to integrate with Exchanges Plan completed review of provider contracts for networks accessed by Exchange PPO (or EPO) members. Plan completed local system changes for Par/Host pricing and Control/Home benefit application. Plan was certified as a QHP by the state or federally-facilitated Exchange. Plan verified systems are set up to accurately populate Provider Classification (C023), Network Availability Indicator (P096), and Provider Type Availability Indicator (P097) and apply correct Par/Host pricing for Exchange products. Plan prepared to issue member ID cards for Exchange business. Plan prepared new disclosure language. Plan educated its local providers on Exchanges as appropriate. Plan educated Exchange members as
*6/1/13
7/1/13 7/1/13 7/1/13
7/1/13 7/30/13 8/1/13
8/1/13 8/1/13
8/1/13
8/1/13 8/1/13
X X X X
X X X X X
8/1/13 8/1/13 8/1/13 8/1/13 103

*Required Date
appropriate.
X X X X
X x X X X X X X X X
Plan educated internal staff on Exchange business as appropriate. Plan received approval for pricing methods and rule combinations. Plan completed set-up of Plan Profiles for Exchange products. Plan completed alpha prefix set-up for National Doctor and Hospital Finder/BlueCard Access Call Center/Mobile App. Plan verified accurate submission of Physician/PCP Status Code Field in BlueCard PPO, new Exchange PPO, Altnet, & Blue Precision PDF files. Plan prepared to issue Exchange PPO member contracts and benefit books. Plan completed Global Certification for ITS Release 13.5. Plan completed submitting cost data to BCBSA for new Exchange PPO networks. Plan prepared to send Exchange PPO network alerts
8/1/13 9/1/13 9/1/13 9/1/13
9/1/13
9/15/13 9/30/13 *9/30/13 12/1/13
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Exhibit 2: Reporting Implementation Progress in BlueServ
Progress Reporting Overview Communicating Plan progress for the BlueCard for Public Exchange Products implementation steps with stakeholders, Plan executives, and BCBSA executives is critical to the overall success of the implementation effort. The objectives of tracking Plan progress are to assist in the management of the system-wide implementation of BlueCard for Exchanges and to ensure that Plans have access to the tools, information, and support they need to be successful. Plans will be required to report on progress against the baseline implementation steps identified in this guide via the BlueServ survey reporting tool, beginning in January 2013. BlueServ is BCBSAs interactive web application used to collect, store, and retrieve Blue Plan information ranging from general organization-level data to project/product-specific information. The base level of reporting will be at the Plan level and the responses will be consolidated into a single report in an effort to provide an accurate status of system-wide progress. The primary implementation contacts will be responsible for updating the survey monthly, by the scheduled dates below. Additionally, implementation status will be posted to BlueWeb monthly. Month January 2013 February 2013 March 2013 April 2013 May 2013 June 2013 July 2013 August 2013 September 2013 October 2013 November 2013 December 2013 Complete Survey by 1/31/13 2/28/13 3/29/13 4/30/13 5/31/13 6/28/13 7/31/13 8/30/13 9/30/13 10/30/13 11/29/13 12/31/13
Access to BlueServ Primary implementation contacts for the BlueCard for Public Exchanges project will be granted access to the survey no later than December 7, 2012. BlueWeb access is required for the BlueServ reporting tool. New BlueWeb users can gain access to BlueWeb through the following link: https://blueweb.bcbs.com/directories/NewUserRegistration. Once logged on to BlueWeb, users can log on to BlueServ, using the same user ID and password for BlueWeb. Upon log on, users will be directed to the page titled My Survey. On that page, Plans will see three surveys related to BlueCard for Public 105

Exchanges Implementation and should respond to only the survey applicable to their Exchange participation level: BlueCard for Public Exchange Implementation -PPO or EPO: These steps apply to only Blue Plans that intend to offer a PPO and/or EPO product. Plans who intend to offer other Public Exchange product(s) in addition to a PPO/EPO product should also complete these implementation steps. BlueCard for Public Exchange Implementation -Not Offering PPO or EPO: These steps apply to Blue Plans offering product(s) on Exchanges other than a PPO or EPO product. BlueCard for Public Exchange Implementation -Not Offering Any Public Exchange Products: These steps apply to only Blue Plans that do not intend to participate on Exchanges.
Please contact BlueServ Team (BlueServNotifications@bcbsa.com) if you are unable to see the survey or if you need to make the survey available to other team members The following sections provide an overview of how to access and respond to the survey. For more detailed instructions on BlueServ and how to respond to surveys, please see the BlueServ User Manual that can be accessed via the main BlueServ page: http://bluewebportal.bcbs.com//landingpagelevel3/701600?docId=346. Responding to the Survey To respond to the survey, complete the following steps: 1. From the My Surveys tab, select the National Programs surveys group. Click on the plus sign (+) to expand the group. The BlueCard for Exchanges Implementation survey will be listed. 2. Click on the section name to view detailed survey questions relating to the implementation steps. 3. The survey questions can be responded to individually or in total: To respond to a single question, click on the question. This will expand to allow for entry of the status update. To enter responses to multiple questions, click on Answer/Update All Responses link located at the bottom of the page. This will expand the entire survey for entry. 4. Respond to questions with details to support the progress report. 5. To report that an implementation step is partially completed: 106

Enter an approximate percentage complete Enter the scheduled end date Enter additional details on the progress, including of issues encountered, in the Comments area
6. To report that an implementation step is fully completed: Enter 100 in the Percent Complete field Enter the Actual Completion Date Enter any additional details in the Comments area 7. To update comments on a step, type over the previously recorded responses. 8. When updates are complete for a BlueServ session, click on Save Responses. 9. After saving, click Back at the top right of the screen until the screen showing the survey sections is displayed. 10. Check the box for the survey section, then click Mark Section as Complete. The Last Completed date will be updated; Last Completed By will contain your name. 11. Click Proceed to Sign off at the bottom of the page after you have entered the status of all required milestones. When the new screen is displayed, click on the Sign Off link in the upper right corner. Note that this Sign Off is different from the final Sign Off required by the BlueCard Executive at the end of the implementation of BlueCard for Exchanges. Signing off of the survey does not prevent future entries.
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EXHIBIT 3: Disclosure Language
NOTE: This revised disclosure language has not yet been approved by the Board. Revised disclosure language provisions for Exchange individual and group products will be incorporated into the revised Inter-Plan Programs disclosure language overhaul expected to be taken through Q3 2013 Governance Cycle for potential approval in September 2013. The revised provisions for Exchange products include language explaining that federal law may mandate liability calculation methods different from those normally used for Inter-Plan arrangements. The memo sent out on August 30, 2012 (IPP-M-12-109) provides Plans with an interim solution for submitting proposed disclosure language when filing products with state regulators prior to Board approval in 2013. This exhibit contains the following IPP disclosure proposed to be included in Exchange member materials: PPO/Traditional self-funded account contracts PPO/Traditional insured account contracts PPO/Traditional and Local HMOs with Out-of-Area Benefits member benefit booklets/individual insured contracts Local HMOs with Out-of-Area Benefits insured account contracts Local HMOs with Out-of-Area Benefits self-funded account contracts Please contact Andrew Korsak (andrew.korsak@bcbsa.com) with questions related to Exchangerelated Disclosure Language. Revised (Federal) and State Law Exceptions Provision for PPO/Traditional Self-funded Account Contract IPP Disclosure In some instances federal law or the laws of a small number of states may require Host Blues either (i) to use a basis for determining [employee/member/subscriber] liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should either federal law or the law of the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/Licensee Name] would then calculate [employee/member/subscriber] liability and [your/account name] liability in accordance with applicable law. Current 2009 Model Language State Law Exceptions Provision for PPO/Traditional Self-funded Account Contract IPP Disclosure A small number of states require Host Blues either (i) to use a basis for determining [employee/member/subscriber] liability for covered healthcare services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/Licensee Name]
108

would then calculate [employee/member/subscriber] liability and [your/account name] liability in accordance with applicable law. Revised (Federal) and State Law Exceptions Provision for PPO/Traditional Insured Account Contract IPP Disclosure In some instances federal law or the laws of a small number of states may require Host Blues either (i) to use a basis for determining [employee/member/subscriber] liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should either federal law or the law of the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/Licensee Name] would then calculate [employee/member/subscriber] liability in accordance with applicable law. Current 2009 Model Language State Law Exception Provision for PPO/Traditional Insured Account Contract IPP Disclosure A small number of states require a Host Blue either (i) to use a basis for determining [employee/member/subscriber] liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/Licensee Name] would then calculate [employee/member/subscriber] liability in accordance with applicable law.
Revised (Federal) and State Law Exceptions Provision for PPO/Traditional and Local HMO with Out-of-Area Benefits Member Benefit Booklet/Individual Insured Contract IPP Disclosure Federal law or the laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If federal law or any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered healthcare services according to applicable law. Current 2009 Model Language State Law Exception Provision for PPO/Traditional and Local HMO with Out-of-Area Benefits Member Benefit Booklet/Individual Insured Contract IPP Disclosure Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered healthcare services according to applicable law. Revised (Federal) and State Law Exceptions Provision for Local HMO with Out-of-Area Benefits Insured Account Contract IPP Disclosure In some instances federal law or the laws of a small number of states may require Host Blues either (i) to use a basis for determining [employee/enrollee/member/subscriber] liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should either federal law or the law of the state in which healthcare services are accessed mandate liability calculation methods that 109

differ from the negotiated price methodology or require a surcharge, [we/HMO Licensee Name] would then calculate [employee/enrollee/member/subscriber] liability in accordance with applicable law. Current 2009 Model Language State Law Exception Provision for Local HMO with Out-of-Area Benefits Insured Account Contract IPP Disclosure A small number of states require a Host Blue either (i) to use a basis for determining [employee/enrollee/member/subscriber] liability for covered healthcare services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/HMO Licensee Name] would then calculate [employee/enrollee/member/subscriber] liability in accordance with applicable law. Revised (Federal) and State Law Exceptions Provision for Local HMO with Out-of-Area Benefits Self-funded Account Contract IPP Disclosure In some instances federal law or the laws of a small number of states may require Host Blues either (i) to use a basis for determining [employee/enrollee/member/subscriber] liability for covered medical expenses that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should either federal law or the law of the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/HMO Licensee Name] would then calculate [employee/enrollee/member/subscriber] liability and [your/account name] liability in accordance with applicable law. Current 2009 Model Language State Law Exceptions Provision for Local HMO with Out-ofArea Benefits Self-funded Account Contract IPP Disclosure A small number of states require a Host Blue either (i) to use a basis for determining [employee/enrollee/member/subscriber] liability for covered healthcare services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, [we/HMO Licensee Name] would then calculate [employee/enrollee/member/subscriber] liability and [your/account name] liability in accordance with applicable law.
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EXHIBIT 4: Provider Education Material
This Exhibit contains provider education material on the Exchange Individual Grace Period (standard language for providers). Additional provider education material on the new member ID card indicator for public Exchange members with access to the National Exchange Qualified PPO network as well as the new National Exchange Qualified PPO network name will be developed in first quarter 2013. Templates will also be available on the Provider Education Material website on BlueWeb: http://bluewebportal.bcbs.com/landingpagelevel3/704100?docId=14260 Please contact Cathy Reice (Catherine.Reice@bcbsa.com) with questions related to provider education.
Exchange Individual Grace Period Standard Language For Providers NOTE: The sample provider letter and electronic notification language for the Exchange Individual Grace Period has not yet been approved by Governance. If an individual enrolled in an Exchange product receives a tax credit, the QHP issuer must allow a three-month grace period. Federal legislation requires that during the grace period, the issuer must notify providers of the possibility for denied claims during the second and third months. This Exhibit includes the standard messaging that Par/Host Plans must send to local providers to notify about the possibility of denied claims. Note that this standard messaging is scheduled to be taken through Q1 2013 Governance for potential approval.
Sample Provider Letter Exchange Individual Grace Period

<Host Plan Name and/or Logo> <Date> <Provider Name> <Provider Address> <Provider Address> <Provider Address>
Member Name:_________________ Member ID:___________________ Date of Service:_________________ Total Charge:___________________ Member Acct #:_________________ Claim #:________________________
Dear <Practitioner Name>: Under the Patient Protection and Affordable Care Act (PPACA), there is a three month grace period under Exchange-purchased individual insurance policies, when a premium due is not received for members eligible for premium subsidies. During this grace period, carriers may not 111

disenroll members and, during the 2nd and 3rd months of the grace period, are required to notify providers about the possibility that claims may be denied in the event that the premium is not paid. Please be advised that a premium due has not been received for this subsidy eligible member and that the member and any eligible dependents are and at the time that your care was provided, were in the second or third month of the Exchange individual health insurance grace period. The above-referenced claim thus was pended due to non-payment of premium, and will be denied if the premium is not paid by the end of the grace period. Please feel free to contact [Host Plan Name] Monday through Friday, [Host Plan hours of operation], at the number listed below if you have any questions regarding this claim. Sincerely, [Host Plan Name] xxx-xxx-xxxx
Language to be included in electronic notifications to providers Exchange Individual Grace Period:

Please be advised that premium has not been received for this premium subsidy eligible member and that the member is and at the time that your care was provided, in the second or third month of the Exchange individual grace period. The above-referenced claim was pended due to nonpayment of premium, and it will be denied if the premium is not paid by the end of the grace period.
112

Exhibit 5: Federal Legislation and Regulation References
The United States Department of Health and Human Services (HHS) published the following rules regarding provisions of the Patient Protection and Affordable Care Act that provide the framework to assist states in setting up Health Insurance Exchanges: March 27, 2012: Final and Interim Rule: Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers Published March 27, 2012: https://www.federalregister.gov/articles/2012/03/27/2012-6125/patient-protection-andaffordable-care-act-establishment-of-exchanges-and-qualified-health-plans#p-3 August 17, 2011: Patient Protection and Affordable Care Act; Exchange Functions in the Individual Market: Eligibility Determinations; Exchange Standards for Employers Published August 17, 2011: https://www.federalregister.gov/articles/2011/08/17/2011-20776/patient-protection-andaffordable-care-act-exchange-functions-in-the-individual-market-eligibility July 15, 2011: Proposed Rule: Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans Published July 15, 2011: https://www.federalregister.gov/articles/2011/07/15/2011-17610/patient-protection-andaffordable-care-act-establishment-of-exchanges-and-qualified-health-plans August 3, 2010: Request for Comments: Planning and Establishment of State-Level Exchanges; Request for Comments Regarding Exchange-Related Provisions in Title I of the Patient Protection and Affordable Care Act Published August 3, 2010: https://www.federalregister.gov/articles/2010/08/03/2010-18924/planning-andestablishment-of-state-level-exchanges-request-for-comments-regarding-exchangerelated
The Patient Protection and Affordable Care Act (PPACA): http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
113

Exhibit 6: Inter-Plan Policy References
The policies listed in the following table include information for BlueCard for Exchanges. Inter-Plan Programs Policies and Provisions related to BlueCard for Exchanges: IP 1.09 IP 1.18 IP 1.19 IP 3.08 IP 3.09 IP 3.11 IP 8.03 IP 15.01 IP 15.02 IP 15.03 Identification Card Requirements Participating Provider Data National Consumer Cost Tool Par/Host Licensee Access Fees Par/Host Licensee Expense Reimbursement Disclosures Custom Networks for National Accounts Public Exchange PPO Provider Networks Identifying the Headquarters for Public Exchange-based National Accounts Public Exchange PPO Enrollment
114

Exhibit 7: Sample Q2 2013 Survey Questions to Determine Inclusion in a Defined, National, Pre-deployed Exchange Qualified PPO Network
In early Q2 2013, BCBSA will issue an all Plan survey requesting information on Plans networks accessed by Exchange PPO or EPO members. Plans will be asked for information related to: inpatient, outpatient, and professional discounts for each network number of counties covered by each network
number of counties in Plans licensed service area

SAMPLE QUESTIONS 1. Does your Plan intend to offer an individual or SHOP Exchange PPO (or EPO) product in 2014? Answer: Yes or No Note: If the answer is no, please answer not applicable for the remaining questions. 2. How many counties are in your Licensees service area? Answer: Free Form 3. If your Plan will offer an Exchange PPO product, how many different networks will your Exchange PPO members access? Answer: 1, 2, 3, 4, 5, 6, Other, or Not Applicable 4. If your Exchange PPO members will access 2 or more networks, do any of the networks accessed by Exchange PPO members overlap in one or more counties? Answer: Yes, No, Not Applicable Exchange PPO Network 1 5. For the first Exchange PPO provider network, please provide the name(s) of the Exchange PPO network(s) and product ID. Answer: Free Form text or Not Applicable 6. For the first Exchange PPO provider network, please provide the average discount rate (% of charges) for the following claims types for the network(s) listed in the previous question (if not available, provide best estimate): a. Inpatient (free form) b. Outpatient (free form) 115

c. Professional (free form) d. Not applicable 7. For the first Exchange PPO provider network, how many counties does the network service? Answer: Free Form or Not Applicable 8. For the first Exchange PPO provider network, does the network overlap with another Exchange PPO network? Answer: Yes, No, or Not Applicable 9. If the first Exchange PPO provider network overlaps with another Exchange PPO network, please list the Product ID(s) of the overlapping Exchange PPO network(s). Answer: Free Form or Not Applicable Exchange PPO Network 2 10. For the second Exchange PPO provider network, please provide the name(s) of the Exchange PPO network(s) and product ID. Answer: Free Form text or Not Applicable 11. For the second Exchange PPO provider network, please provide the average discount rate (% of charges) for the following claims types for the network(s) listed in the previous question (if not available, provide best estimate): a. b. c. d. Inpatient (free form) Outpatient (free form) Professional (free form) Not applicable
12. For the second Exchange PPO provider network, how many counties does the network service? Answer: Free Form or Not Applicable 13. For the second Exchange PPO provider network, does the network overlap with another Exchange PPO network? Answer: Yes, No, or Not Applicable 14. If the second Exchange PPO provider network overlaps with another Exchange PPO network, please list the Product ID(s) of the overlapping Exchange PPO network(s). 116

Answer: Free Form or Not Applicable
117
VERSION 1.0 January 10, 2013 Revision Log

Date 10/4/12 Revision Description Changed National Provider Finder to National Doctor and Hospital Finder Chapter 2 Operations Changed - Throughout implementation dates Chapter 4 Additional Comment added Information Fees Policy Number added Chapter 5 Exhibits Changed implementation dates Chapter 4 Additional Added section on Information BlueCard Worldwide Chapter 4 Additional Added information to Information section on SHOP Exchange enrollment Chapter 2 Operations Added new PPO B ID card logo Throughout Document Made formatting, spelling, capitalization changes for clarity and consistency. Chapter 1 Added section Naming the Qualified PPO Network Chapter 1 Updated with information from Fall 2012 Survey information Chapter 4 Individual Added bullet points and Grace Period information, made into a new section Chapter3 Added both sections to Control/Home Benefit document, made Scenarios, Par/Host formatting changes to Pricing Scenarios fit them into this document Chapter 4 Added information to Additional section SHOP Information exchange enrollment Chapter 5 Exhibits Added section on BlueServ, renumbered Exhibits Chapter- Section Throughout Document Revised By A. Crissie
10/4/12 10/4/12 10/4/12 10/4/12 10/4/12
A. Crissie A. Crissie A. Crissie A. Crissie A. Crissie
10/4/2012 10/4/2012
A Crissie A Crissie
10/16/2012
A Crissie
10/16/2012
A Crissie
10/16/2012
A Crissie
10/16/2012
A Crissie
10/19/2012
A Crissie
10/19/2012
A Crissie
118

10/19/2012 10/22/2012 Added policy to table Changed dates and information on disclosure language Chapter 4 Network Added sentence Reporting Services explaining new search fields and reasoning Chapter 2 Disclosure Changed dates and Language information on disclosure language Chapter 5 Exhibit 1 Deleted sign-off from form, changed implementation dates Chapter 5 Exhibit 1 Changed implementation dates, added implementation steps Definitions Updated Exchange definition Chapter 2- Operations Added information on categorization of implementation steps to the introduction section. Chapter 2- Operations- Change implementation Throughout dates Chapter 2- Operations- Added Plan Exchange Throughout participation level to each implementation step. Chapter 2- Operations Added review schedule to section on compliance impacts. Chapter 2- Operations Added ID card indicators to the section on ID cards. Chapter 3 Added provider class 9 Control/Home Benefit to the ITS legend. Scenarios, Par/Host Pricing Scenarios Chapter 3 Updated Control/Home Control/Home Benefit Benefit Scenarios Scenarios, Par/Host Pricing Scenarios Chapter 4 Individual Added updated Grace Period information to the Control/Home and Chapter 5 Exhibits Chapter 5 - Exhibits A Crissie A Crissie
10/22/2012
A Crissie
10/24/2012
A Crissie
10/24/2012
A Crissie
10/26/2012
A Crissie
12/18/2012 12/18/2012
T. Carruthers T. Carruthers
12/18/2012 12/18/2012
T. Carruthers T. Carruthers
12/18/2012
T. Carruthers
12/18/2012
T. Carruthers
12/18/2012
T. Carruthers
12/18/2012
T. Carruthers
12/18/2012
T. Carruthers
119

Par/Host responsibilities section. Added reference to the provider education materials available in Exhibit 4. Categorized each Plan implementation step according to Plan Exchange participation level. Added implementation steps to the checklist. Updated the survey due date schedule. Added standard provider notification language for Individual Exchange Grace Period.
12/18/2012
Chapter 4 Individual Grace Period
T. Carruthers
12/18/2012
Chapter 5-Exhibit 1
T. Carruthers
12/18/2012 12/18/2012 12/18/2012
Chapter 5-Exhibit 1 Chapter 5- Exhibit 2 Chapter 5- Exhibit 4
T. Carruthers T. Carruthers T. Carruthers
120

Implementation Guide: Bluecard For Public Exchange Products: VERSION 1.0 - January 10, 2013

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Implementation Guide: Bluecard For Public Exchange Products: VERSION 1.0 - January 10, 2013

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VERSION 1.

0 January 10, 2013

IMPLEMENTATION GUIDE: BLUECARD FOR PUBLIC EXCHANGE PRODUCTS Version 1.0

VERSION 1.0 January 10, 2013

VERSION 1.0 January 10, 2013

VERSION 1.0 January 10, 2013

VERSION 1.0 January 10, 2013 CHAPTER 1: OVERVIEW

VERSION 1.0 January 10, 2013

Bill Witt Angela Harris Nancy Williams

312.297.5874 312.297.6921 312.297.6503 312.297.5675 312.297.6335 312.297.6640

Derek.Morris@bcbsa.com Brenda.Muehlbauer@bcbsa.com Andrew.Korsak@bcbsa.com Ken.Matuszak@bcbsa.com Christopher.Oh@bcbsa.com Chad.Jacobs@bcbsa.com

BlueCard for Public Exchange Products Contacts

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BlueCard for Public Exchange Products Implementation Conference Calls

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2014 BlueCard for Exchanges Plan Participation

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Naming the National Exchange Qualified PPO Network

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Designate an Exchange Compliance Contact

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Make Preliminary Decisions on Exchange Products and Network Access

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Traditional POS HMO

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Notify BCBSA of any Inter-Plan Exchange Compliance Impacts

IPP Processing Standards

BCBSA Posts Initial Analysis

Plan Review Deadline

7.01-10.01 National Accounts, Adjustments, International Claims, Grievances and Appeals

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Complete Set-up for Print-On-Demand Directories

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Network Type BlueCard PPO Qualified PPO BlueCard Traditional

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Set-up Plan Profiles

Prepare New Disclosure Language

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Internal Customer Service Staff Training

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Complete Global Certification for ITS Release 13.5

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Prepare to Send Network Alerts for new Exchange PPO Networks

VERSION 1.0 January 10, 2013 CHAPTER 3: SYSTEMS

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Par/Host Plan Pricing Scenarios