Blue Cross Blue Shield of North Dakota (BCBSND) wants to provide more information regarding the Coordinated Service Program (CSP) that applies to the Medicaid Expansion line of business.
Members utilization is periodically reviewed, to monitor incorrect, improper, or excessive utilization of the emergency department for services that could be treated on a non-emergent basis and/or multiple prescribers or pharmacies to fill medications that have risk of potential abuse. Review is done by BCBSND in consultation with the North Dakota Department of Health and Human Services. Members placed in the CSP will be designated one coordinated service medical prescriber and one pharmacy provider who will collaborate regularly with them to understand their health care needs and coordinate their care. The designated coordinated services medical prescriber can also refer members to specialist prescribers for additional care. Services performed from non-prescribers, such as a physical therapist, for example, will not be required to get a referral from the designated CSP provider, but will be subject to any existing referral requirements of the members plans.
Claims received for services rendered by the non-designated prescriber will be denied as member liable, except for medical care rendered in a medical emergency or medical care rendered by a provider who has an approved BCBSND referral from the designated CSP prescriber. The member or member’s authorized representative has the right to appeal the claim(s) if they disagree.
If a provider has any past Medicaid Expansion claims that were denied as provider liable for a member who sought care outside their designated CSP PCP prescriber, the provider has the right to file a dispute. More information regarding the CSP and provider disputes, can be found within the Medicaid Expansion provider manual under sections Coordinated Services Program (CSP) and Provider Dispute Process. More information regarding CSP will be updated within the next 30 days.
For any questions, please contact the Medicaid Expansion Provider Service Center at 1-833-777-5779.