CurrentEmpire BluecrossPolicy N/A

Advance Patient Notice for Use of an Out-of-Network Breast Reconstruction Surgeon

Requires mastectomy surgeons to provide and obtain a signed Advance Patient Notice (APN) before referring or scheduling a member with an out-of-network breast reconstruction surgeon in non-emergent situations, ensuring members understand financial implications and options.

Policy Summary

PayerEmpire Bluecross

PolicyAdvance Patient Notice for Use of an Out-of-Network Breast Reconstruction Surgeon

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2014

Next Review DateN/A

Key ActionProvide the enclosed APN form and obtain the member's signature prior to scheduling services or referring to an out-of-network breast reconstruction surgeon; retain original and give copy to the member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2014-07-01policy effective date

Non-emergentapplies to

Signed APNrequirement

Original retaineddocumentation

Termination riskenforcement

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When an Advance Patient Notice (APN) is Required

APN requirements and member options

Covered when ALL of the following are met:

APN must be provided and signed prior to scheduling or referring the member to an out-of-network breast reconstruction surgeon for non-emergent procedures.

The APN must be the enclosed Advance Patient Notice form; the provider must retain the original signed form in their files and give a copy to the member.

The APN must inform the member that use of an out-of-network breast reconstruction surgeon may result in greater costs or noncoverage, and that the member has the right to obtain services from an in-network surgeon to receive full benefits.

The APN must include the patient acknowledgements: awareness that the physician is non-participating; responsibility for additional costs unless prior Anthem approval/exception has been granted; opportunity to contact Anthem to confirm benefits and locate in-network providers; prohibition on waiving cost-sharing absent special circumstances; and voluntary choice to proceed.

Members may contact Anthem to request an Out-of-Network Exception prior to scheduling; when Anthem prior approval/exception for the out-of-network referral has been obtained, the APN is not required.

This policy does not apply to emergency situations.

Anthem will track use of out-of-network breast reconstruction surgeons; repeated failure to comply with the APN policy after initial warning may result in termination from the Anthem network.

APN Form Fields and Patient Acknowledgements

APN form fieldsmixed

	Referring Physician Name:______________________________________________________
	NPI #_______________________________________________________________________
	Patient Name:________________________________________________________________
	Member ID#_________________________________________________________________
	Non-Participating Physician Name:_______________________________________________
	Specialty:___________________________________________________________________

APN form fields (single grouped entry)mixed

Form fields include referring physician name, NPI, patient name, member ID, non-participating physician name and specialty.

Patient acknowledgements required

Acknowledgement 1I am aware that the non-participating physician that will be involved in my care does not participate with Anthem.

Acknowledgement 2I have read Anthem's Out-of-Network Exception policy and understand that I will be responsible for additional costs for all services provided by the non-participating physician, as specified in my benefit contract, unless I have received Anthem's prior approval for an in-network exception. I further understand that if I seek an Out-of-Network exception, I should contact Anthem immediately at the Customer Service number on the back of my ID card, prior to scheduling the surgery.

Acknowledgement 3I was given an opportunity to contact Anthem before obtaining these services to confirm my benefits for these non-network services and to obtain names of participating physicians that can provide the recommended service or procedure.

Acknowledgement 4I understand that absent special circumstances (e.g., financial hardship), the non-participating physicians are prohibited from waiving co-payments, deductibles, coinsurance or other member cost sharing amounts.

Acknowledgement 5

Provider Requirements, Exceptions, and Documentation

Documentation Required

APN signature and retention

Provide the member with the Advance Patient Notice (APN) form and obtain the member's signature prior to scheduling services with or referring to an out-of-network breast reconstruction surgeon. Retain the original signed APN in your records and give a copy to the member. The APN must be the Anthem APN form; it should be presented before the procedure is scheduled or the referral is made so the member can contact Empire BlueCross for information about obtaining an exception for the out-of-network surgeon.

Give member the updated Anthem APN form for signature prior to scheduling services or making the referral
Retain the original signed APN in the provider's files and provide a copy to the member
Ensure the mastectomy/in-network surgeon knows whether the reconstruction surgeon participates in the network

Prior Authorization

Exceptions to APN requirement

The APN requirement does not apply in emergency situations. The APN is also not required when Empire BlueCross (Anthem) prior approval for the referral or use of the out-of-network physician has been obtained in advance. When prior approval has been granted, the referral may proceed without the APN, but the service remains subject to member benefits and any applicable Anthem policies (including network exception policies and referral rules). Repeated failure to comply with the APN requirement after an initial warning may result in termination from the Anthem network.

Key Terms

APN — Advance Patient Notice (definition)

DefinitionAdvance Patient Notice (APN): A written notice provided to members when an in-network mastectomy surgeon refers or schedules the member with an out-of-network breast reconstruction surgeon in non-emergent situations to ensure the member is informed of potential financial implications and options.

When requiredAPN must be provided and signed prior to scheduling or making a referral to an out-of-network breast reconstruction surgeon for non-emergent procedures.

Retention and copiesOriginal signed APN must be kept on file by the provider and a copy given to the member; Anthem may request the form and will track use.

Out-of-Network Exception — definition

DefinitionOut-of-Network Exception (prior approval): Anthem's prior approval process that, when granted in advance, allows use of an out-of-network physician without completing the APN form.