Attention Blue Shield HMO Members:
Effective May 1, 2012, Blue Shield has terminated their HMO contract with our local IPA carrier, Monarch Healthcare. This change in status is causing significant concern to patients, parents, providers and brokers. These contract issues are COMPLETELY out of our control. The quality of care to our patients is very important to us, as is the continuity of care. Please refer to the information listed below for answers to common questions, and what you can do to AVOID any delay in care to your child. As always, we are here to help YOU! If you still have questions, please contact our office directly, so we can be of further assistance in this time of transition from one plan to another. We are hopeful that you will be able to remain a member of our SOCPA family, and not allow this event to affect the care of your child.
How has this affected our SOCPA patients?
Unfortunately, this decision no longer allows you to choose one of our SOCPA providers as an “in network” primary care physician for your child; which could include care to other network specialists. Several of our patients have been reassigned to a new, unknown PCP and IPA group, often times outside of the area. Southern Orange County Pediatric Associates understands the frustration involved with these changes. Our primary concern is to provide quality continuity of care to our patients.
PLEASE NOTE* This will not affect patients that carry a Blue Shield PPO contract. This decision ONLY affects the Blue Shield HMO members. SOCPA will remain contracted as HMO providers through Monarch Healthcare with other HMO carriers (Aetna, Blue Cross, Caloptima, Cigna, Health Net and United Healthcare) along with most major PPO plans.
What are the options available to our Blue Shield HMO Members?
Please understand that we are happy to continue care for all Blue Shield members, however, we can only bill insurance for the Blue Shield PPO members. All HMO patients may be seen on a private pay basis. The only exception to this rule would be for patients that have obtained authorization for continuity of care coverage directly from Blue Shield.
How do I obtain an authorization for continuity of care coverage?
Parents/patients must contact their Member Services department at the number listed on their health insurance card. Blue Shield will request that members complete a Continuity of Care Request Form and return it to Blue Shield. Blue Shield will then request medical records from our office. After receiving the chart notes, Blue Shield will then make a determination for coverage; typically within 5 business days. The member and the physician will both receive written notification of their decision making. So far responses have included approval for care as follows: 1) just for well care/immunizations, 2) newborn/infant care (sick and well visits-generally for children under the age of 36 months) or 3) for follow up care on a specific diagnosis or treatment. All approvals are for a limited amount of time. We have not seen an approval past a one year term. All referrals to outside specialists will require a prior authorization from the new IPA Group, and are subject to approval. As always, coverage is based on eligibility. Blue Shield has also denied continuity of care requests; indicating that members can be “safely transferred to a network provider without undue disruption.” Continuity of care is determined on an individual basis. SOCPA will not bill for such services until we have a written authorization from Blue Shield. Approved members will be asked to sign a waiver form at the time of each service. All claims left unpaid by Blue Shield will be the responsibility of the member.
As a parent/patient, what can you do?
Continuity of care is of top concern to our practice. We would encourage you to seek other options for coverage that would allow you to stay with your child’s primary care physician. Contact your human resource department or broker and VOICE YOUR CONCERNS. Most importantly, don’t be afraid to contact Blue Shield directly. Monarch Healthcare is also proactively assisting members with other options. For more information on high-quality plans that will guarantee access to your providers of choice, please visit www.DontLoseYourDoc.com.