Currentblue cross blue shield - michiganPolicy BCNA

Remote patient monitoring (telemonitoring) — BCN Advantage Individual

Defines coverage, program administration, and member eligibility for remote patient monitoring (telemonitoring) under BCN Advantage Individual Medicare Advantage plans, including targeted conditions, vendor administration, and reimbursement rules.

Policy Summary

Payerblue cross blue shield - michigan

PolicyRemote patient monitoring (telemonitoring) — BCN Advantage Individual

Policy CodePolicy BCNA

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateNov 18, 2024

Key ActionConfirm member enrollment and BCN referral before initiating vendor-delivered telemonitoring.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

HF, COPD, HTNConditions targeted for RPM enrollment

No costMember cost share

Single vendorProgram delivery

Vendor contractReimbursement

Coverage Criteria for BCN Advantage Individual RPM

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BCN Advantage Individual RPM coverage criteria

Covered when ALL of the following are met

Enrollment and program participation: Member is enrolled in and agrees to participate in the Chronic Condition Management (CCM) program and is referred to the BCN-contracted telemonitoring vendor.

BCN verifies eligibility prior to referral.

Targeted diagnoses: Member has a diagnosis of heart failure OR chronic obstructive pulmonary disease OR uncontrolled hypertension.

These conditions are targeted by care management for the remote monitoring intervention.

Service delivery and administration: Telemonitoring services are provided under the administration of the CCM program and delivered by a single BCN-contracted provider; the vendor supplies the monitor, transmission, and daily clinician review.

Vendor payments and service reimbursement are managed under BCN contract; no separate billing to member for vendor services.

Original Medicare limits coverage of remote patient monitoring (telemonitoring) to services provided as part of a home health plan of care and combined with another skilled service. Blue Care Network’s BCN Advantage Individual plan offers RPM as an enhanced benefit; however, BCN defines the program scope and administration for its members and delivers services through a single BCN-contracted vendor under the Chronic Condition Management (CCM) program. Providers should recognize that BCN’s coverage and vendor-based delivery model operates within the broader constraint that Original Medicare restricts RPM to home health plan settings when applicable.

BCN handles member eligibility verification and referral into the RPM program and manages reimbursement through contracts with the vendor so that members do not receive separate vendor billing. Providers must confirm BCN referral/eligibility and follow the BCN CCM program procedures when initiating telemonitoring services for BCN Advantage Individual members.

Provider Responsibilities and Enrollment Process

Note

Program administration requirement

Enrollment in the remote patient monitoring benefit is provided to members who meet clinical criteria and who agree to participate in the Chronic Condition Management (CCM) program. Telemonitoring services are administered as part of the CCM program and are delivered by a single BCN‑contracted vendor under the terms of BCN's contract. Because services are delivered by the contracted vendor, vendor service payments are administered per that contract and providers do not bill members for these telemonitoring services.

Services must be provided under the CCM program and delivered by the BCN‑contracted single‑source vendor.
Vendor payments are administered under the contract; providers do not bill the member for vendor‑delivered telemonitoring services.

Prior Authorization

Eligibility verification and referral

Blue Care Network verifies member eligibility for the telemonitoring program prior to referring the member to the contracted vendor. Providers should not refer members to the vendor for telemonitoring until BCN has confirmed program eligibility. Because the vendor administers services under contract, there is no member billing by the provider for these services.

BCN verifies member eligibility prior to referral to the contracted telemonitoring vendor.
Providers must await BCN eligibility verification before referring members for telemonitoring services.

Note

Care management targeting

Care management may target eligible members diagnosed with specified chronic conditions for the remote monitoring intervention. Eligible diagnoses that may be targeted include heart failure, chronic obstructive pulmonary disease (COPD), and uncontrolled hypertension. Members enrolled in the remote monitoring program are provided a symptom‑appropriate monitor that transmits daily data to health care professionals who will review and take action as needed, and members receive support to operate the equipment.

Eligible members may be targeted based on diagnosis of heart failure, COPD, or uncontrolled hypertension.
Members receive a symptom‑appropriate monitor and operational support; transmitted data are reviewed daily by health care professionals who act as needed.

Background on Remote Patient Monitoring

Remote patient monitoring (also called telemonitoring) is an ambulatory care model in which a patient uses an internet-capable device to perform routine physiologic tests and transmit data to clinicians for review, analysis, and follow-up. BCN Advantage provides RPM as an enhanced benefit that supplies a symptom-appropriate monitor, daily data transmission, and clinician review as part of the Chronic Condition Management (CCM) program.

Eligible members—typically those targeted by care management for conditions such as heart failure, COPD, or uncontrolled hypertension—are enrolled in and must agree to participate in the CCM program and be referred to the BCN-contracted telemonitoring vendor. The vendor supplies the monitor, manages transmission, and performs daily clinician review while BCN manages program enrollment, referral, and vendor reimbursement.

Key Definitions

inv-08: Remote patient monitoring (telemonitoring) — concise definition and scope

DefinitionRemote patient monitoring (telemonitoring): ambulatory health care in which a patient uses an internet-capable device to perform routine tests and transmit data in real time to a health care professional for analysis and follow-up.

Program scopeOffered as an enhanced benefit under BCN Advantage Individual Medicare Advantage; scope and eligibility are determined by Blue Care Network.

Targeted conditionsProgram targets members with chronic conditions such as heart failure, chronic obstructive pulmonary disease (COPD), and uncontrolled hypertension for enrollment by care management.

Service delivery modelServices are administered through the Chronic Condition Management (CCM) program and delivered by a single BCN‑contracted vendor who provides the monitor, transmission, and daily clinician review.

Member cost responsibilityNo member cost share for vendor‑delivered telemonitoring services under the BCN program.