Resources

Introduction to the BlueHPN

Q: What is the Blue High Performance Network^® (BlueHPN^®)?

The BlueHPN is a national network through Blue Cross and Blue Shield that launched in January 2021. Providers within the BlueHPN service area qualify as BlueHPN providers by meeting quality thresholds. Patients will be guided to providers and hospitals in this network through the BlueHPN benefit plan or other BlueHPN referring providers.

Q: Generally speaking, how does the BlueHPN work?

BlueHPN is a comprehensive network that includes a full range of providers including primary care doctors, ancillary providers, specialists and hospitals. In Alabama, this network focuses on the Birmingham area. Only certain healthcare providers meet requirements to be part of this network. Not all healthcare providers are included. When BlueHPN patients need to see a specialist or another healthcare provider, it’s important that providers only recommend other BlueHPN healthcare providers to ensure these patients will have benefits. Generally, services by non-BlueHPN providers are not covered. (Note: Effective January 1, 2024, urgent care and behavioral health services [mental health and substance abuse] no longer require designations or referrals for coverage.) Providers will be able to use our Find A Doctor tool at AlabamaBlue.com to identify BlueHPN healthcare providers.

Q: What is the Metropolitan Service Area (MSA) for the BlueHPN in Alabama?

The Birmingham MSA consists of zip codes in the following counties: Bibb, Blount, Chilton, Jefferson, St. Clair, Shelby and Walker.

These are the specific zip codes for the Birmingham MSA:

Q: What providers are included in the BlueHPN?

Providers have been selected to be part of this new network. There is no process for providers to apply to participate in this network. Providers who have been designated for this network do not have to take any action. Review the list of providers and hospitals designated for the BlueHPN.

Q: Will existing fee schedules apply?

Yes, existing fee schedules apply to the BlueHPN.

Q: If I am a provider who is not in the BlueHPN, how does this affect me?

If providers have patients who move to the BlueHPN and the provider is not in this network, those patients will not have benefits when receiving care from a non-BlueHPN (out-of-network) provider.

Participation

Q: How do I know if I am a BlueHPN healthcare provider? 

Blue Cross and Blue Shield of Alabama designates healthcare providers to be in the BlueHPN. As a BlueHPN healthcare provider, your practice shows BlueHPN status on our online provider finder tool, Find A Doctor.

Q: Are all the healthcare providers in my practice also in BlueHPN? 

BlueHPN physician providers are designated at the individual level rather than the practice level, so it is possible that all providers in a practice will not be part of the BlueHPN. Our Find A Doctor tool at AlabamaBlue.com indicates individual physician status.

Q: If I am currently a Blue Distinction Specialty Care (BDSC) or Total Care designated healthcare provider, am I still a BDSC and/or Total Care designated healthcare provider within BlueHPN? 

Yes.

Q: If I have or my organization has a value-based contract with Blue Cross and Blue Shield
of Alabama, will this apply to BlueHPN patients (i.e., will BlueHPN patients be attributed)? 

Yes, value-based contracts will apply to the BlueHPN.

Q: Are Medicare and Medicaid patients included in BlueHPN?

No. BlueHPN is only offered to individuals and employer groups at this time.

Quality Measurement

Q: Is there a quality performance threshold that determines BlueHPN healthcare provider inclusion?

Yes, there is a quality performance threshold for determining BlueHPN provider inclusion as follows: Hospitals and physicians must meet quality metric performance standards.

Q: Do I need to provide quality data to Blue Cross and Blue Shield of Alabama?

Providers and hospitals will not need to provide data to us.

Q: Are healthcare providers measured in aggregate or on an individual basis?

BlueHPN healthcare providers are measured individually and at an aggregate network level. Quality is measured across all aspects of care delivery (e.g., inpatient, outpatient) and within each provider type (e.g., primary care, specialist, hospital or health system). This approach was established because:

• Individual performance results allow us to identify opportunities for improvement and to recognize higher value care
• Aggregating quality results allows us to understand BlueHPN market level performance in comparison to our BlueCard PPO healthcare provider population

Q: How are local healthcare providers measured, and how often are they re-evaluated for inclusion?

Certain primary care physicians in the Birmingham MSA are included in the BlueHPN. For the purpose of the BlueHPN, providers are scored on an annual basis. Providers that are designated as primary care physicians during the annual scoring period are locked in to the BlueHPN status for the year. Providers will be notified through Provider Insights when they lose primary care physician status.

Hospital providers will be evaluated according to the following: (1) quality metrics that they currently submit to Hospital Compare; (2) our readmission index measurement for the individual hospital; and (3) CMS overall readmission rate for the individual hospital. Hospitals are scored and results are locked in for two years. Hospitals will be notified of their status in the BlueHPN network.

Q: What tools are available to healthcare providers to improve performance?

Providers can continue to benefit from the numerous tools we have available to help them care for their patients. This includes information and resources available on our provider portal, AlabamaBlue.com/providers, such as the Patient Health Snapshot, Provider Insights and, for hospitals, the Facility Inpatient Report and the Hospital Profile Report.

Eligibility, Benefits and Claims Submission

Q: What do I need to do differently for BlueHPN patients versus BlueCard PPO patients?

In general, the same procedures apply for both BlueHPN and BlueCard PPO patients. For example, you will check eligibility and benefits and submit claims using the same contacts and procedures as you do today. One thing to keep in mind, however, is that BlueHPN patients only have benefits when receiving care from a non-BlueHPN healthcare provider if it is an urgent and/or emergent service (accidental injury/medical emergencies). This may influence how you refer BlueHPN patients for specialty care.

Patient Referrals

Q: My patient needs specialty care and the specialist I usually refer patients to is not in BlueHPN. What do I do?

It is essential to identify specialists that are in BlueHPN using provider finder tools before making a recommendation to your patient. This is meant to avoid having your patient pay unexpected out-of-pocket costs. Use our Find A Doctor search tool to locate providers in the BlueHPN or call Provider Networks at 1-866-904-4130.

Q: My patient needs specialty care and there are no specialists to treat the specific condition in BlueHPN. What do I do?

Please contact Provider Networks at 1-866-904-4130 as there are exceptions to make sure your BlueHPN patients get the care they need.

Billing Issues

Q: How is balanced billing handled through the BlueHPN?

When a BlueHPN member is treated by an BlueHPN provider:

• The member is responsible for copay and deductible, as indicated in benefits.

When a BlueHPN member is treated by a non-BlueHPN provider:

• The member is responsible for the billed charges (no hold-harmless in place).
• Note: There is an exception for emergent care (accidental injury/medical emergencies) (see below).

When a BlueHPN member is treated by a non-BlueHPN provider for emergent care (accidental injury/medical emergencies):

• BlueCard PPO providers will be reimbursed according to the Blue Cross and Blue Shield of Alabama PPO provider contract.
• If the provider is not in the BlueCard PPO network, the service will be considered out-of-network and the member will be responsible for the charge (no hold-harmless in place).