2017 Qualified Health Plans Educational Webinars. Frequently Asked Questions (FAQ) from sessions held week of: 1/2/2017 1/6/2017

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1 2017 Qualified Health Plans Educational Webinars Frequently Asked Questions (FAQ) from sessions held week of: 1/2/2017 1/6/ Can a specialist submit for preauth or will this have to go through the PCP? 2. It is my understanding that if the service needed is not available in the Hometown North network and we have to send our patients to Kootenai Health for specialists, these services will be processed as in-network? 3. If an ambulatory surgery center (ASC) bills for a surgery, does the ASC also need to put the referring PCP in box 17? 4. Are referrals from a PCP to in-network specialists automatically approved? 5. How long are referrals from a PCP to a specialist valid for? 6. As a specialist requesting authorization for CT scans, do we still go through the AIM portal or do these now go through the referral portal? 7. If we have a referral for a patient to see our provider and he needs to order imaging or other services, does the referral cover these services or do we still need a separate referral for each service? 8. Is there a way to get more urgent gap referrals if it is felt that the patient should not wait that long? 9. Will retro referrals be approved? 10. With the understanding that authorizations for services still must obtained either through AIM or the referral portal (JIVA), what about the radiologist that is reading the imaging? Do we need a referral for that? 11. Can one office have more than one login for bcidaho.com? 12. If a specialist must refer the patient to another specialist, must they go through the PCP? 13. If we don t have a copy of the patient s insurance card and the patient gives us their ID number so we may check their eligibility, will their eligibility say if their policy is one of the new QHP plans? 14. Did I hear correctly that an ambulatory surgery center (ASC) does not need a referral? 15. Can you show us where we find a list of our patients? 16. Where can we find a list of alpha prefixes for QHP members? 17. Where do we sign up for JIVA, the online referral tool?

2 18. For x-ray claims, whose name should appear in box 17? 19. I do prior authorizations for multiple physicians and offices for their patients to be sent to a facility for diagnostic testing. Do I or the facility need to be concerned if the patient is being sent from a specialist that there is a referral in place for that specialist? 20. When looking at authorization status, does processed mean the referral was approved? 21. Are claims processed as member liability or provider liability if referrals or prior authorizations are not obtained? 22. Do the True Blue Medicare Advantage plans need referrals? 23. We have many patients who live in Idaho but deliver their babies in Wyoming, which is out-of-network. Patients are telling us that Blue Cross of Idaho is requiring them to obtain a gap referral for this hospital. How do we do this? Is it an inpatient referral? If so, how would we know an admission date and how far in advance does this need to be done? 24. Where are the weekly webinar FAQs posted? 25. Are these referrals only necessary for Blue Cross of Idaho plans obtained through the healthcare exchange or do the plans offered through employers also need referrals? 26. Are facilities required to have their own referral? 27. We have a patient whose network is Hometown North. Per the Provider Directory, it shows the patient s preferred PCP is contracted with Kootenai Care Network but not the Hometown North network. Will a referral request be considered out-of-network? 28. We are an ASC and if we need a referral or authorization, does our name need to be on the referral and/or authorization for it to be valid for us? 29. Where on the Blue Cross of Idaho website can we find the patient s PCP? 30. We have patients who live in the Hometown East network that are currently receiving chemotherapy at our Mountain View network facility. What do we do with them? Do we have to hold treatment until they can get an approved gap referral? 31. Podiatrists have never had to have a referral before. Do we have to have one now? 32. We just tried to access the online referral system (JIVA), and we are receiving a message that says that our browser is not compatible. What does this mean? 33. Some of our QHP patients have not yet picked a PCP. Is there a grace period offered to patients while they are deciding on one? If patients have not yet picked a PCP, how can specialists obtain referrals? 34. Can you please further clarify oncology services? Is it the specialist that needs the referral or the specialist and the facility that administers chemotherapy that needs a referral?

3 35. We are an urgent care and family practice office that is located in Madison County and therefore are in the Hometown East network. When searching our facility in the provider directory, it shows that we accept Hometown East and Mountain View networks. Does that mean we can accept patients from either network without a referral? 36. Are these webinars recorded and will they be available to view online at a later time? Answers 1. Can a specialist submit for preauth or will this have to go through the PCP? Specialists must obtain their own prior authorization for any services that require it. Referrals must be submitted by the PCP for the patient to see a specialist. Remember that referrals are for provider to provider. Prior authorization is a pre-service request to validate medical necessity. 2. It is my understanding that if the service needed is not available in the Hometown North network and we have to send our patients to Kootenai Health for specialists, these services will be processed as in-network? If a patient must be referred for specialist care outside of their network, an approved gap referral would be required. An approved gap referral would mean that services would process for in-network benefits. Keep in mind that any specialist service that requires prior authorization would need to be requested by that specialist. For a list of services that require prior authorization, please select here. 3. If an ambulatory surgery center (ASC) bills for a surgery, does the ASC also need to put the referring PCP in box 17? Yes. All providers other than PCPs will need to enter the name and NPI of the referring PCP into box 17 of the claim form or box 17b of the electronic claim submission. 4. Are referrals from a PCP to in-network specialists automatically approved? Yes. Referrals from a PCP to an in-network specialist will be approved in a matter of minutes. Out-of-network or gap referrals will take longer to approve and could take up to days. 5. How long are referrals from a PCP to a specialist valid for? Generally, most referrals are approved for the remainder of the current year unless specifically requested otherwise by the PCP. Gap referrals for out-of-network providers may have other time or visit restrictions and this will be communicated to the patient, the PCP, and the specialist by Healthcare Operations.

4 6. As a specialist requesting authorization for CT scans, do we still go through the AIM portal or do these now go through the referral portal? Prior authorization for imaging will still go through the AIM portal. Referrals do no negate the need for prior authorizations. 7. If we have a referral for a patient to see our provider and he needs to order imaging or other services, does the referral cover these services or do we still need a separate referral for each service? Remember that referrals are from provider to provider. Approved referrals allow the specialist to see and treat the patient during the dates that the referral is valid for. However, if any treatment, imaging or surgery requires prior authorization, this must be obtained by the specialist prior to rendering services. 8. Is there a way to get more urgent gap referrals if it is felt that the patient should not wait that long? In step 2 of the referral process through the provider portal, a PCP may chose referral type Urgent to denote the urgency of their request. Also, step 7 of the referral process allows a PCP to explain why they are requesting a gap referral and the urgency of that referral request may also be explained here. For referral entry instructions, select here. 9. Will retro referrals be approved? Providers will have 60 days to request a retro-referral if specific criteria are met. Provider Administrative Policy (PAP) 1005 further explains these criteria. 10. With the understanding that authorizations for services still must obtained either through AIM or the referral portal (JIVA), what about the radiologist that is reading the imaging? Do we need a referral for that? No. Radiology services, including readings, do not require a referral. Referrals will not be required and in-network benefits will apply for the following provider types: radiologist (exception-interventional radiology services), anesthesiologist (exceptionpain management), independent laboratory, and pathologists. 11. Can one office have more than one login for bcidaho.com? Yes. Each individual user should have their own individual username and password. To request additional or delete usernames and passwords, the existing administrator of the bcidaho.com account can logon to the provider portal and select My Account icon at the top of the page. Then select Account Maintenance and then add user. Enter all the information regarding the new user and select finish. To make a modification to an existing user account, select edit to make the necessary changes.

5 12. If a specialist must refer the patient to another specialist, must they go through the PCP? Yes. All referrals must be generated by the PCP. This process is the intent of the 2017 QHP plans in which the PCP is the cornerstone of a patient s care and it is meant to keep the PCP well informed of the specialty care their patient s need. 13. If we don t have a copy of the patient s insurance card and the patient gives us their ID number so we may check their eligibility, will their eligibility say if their policy is one of the new QHP plans? Patient s eligibility will clearly indicate if they are in one of the new tailored network plans. The ID card that may be printed from a patient s eligibility screen will have the network name at the top, middle, and bottom banner of the card. The phrase referrals required will also be listed on the card. To view specific examples of ID cards, select the 2017 Qualified Health Plans link on the right side of the main page of the provider portal. You may then select your region from the state map that will appear and examples of ID cards will be listed. 14. Did I hear correctly that an ambulatory surgery center (ASC) does not need a referral? Yes but only if the ASC is in-network with the patient s plan. The referral issued to a specialist will follow that specialist regardless of where the specialist renders services. If, however, the ASC is out-of-network for the patient, then a referral would be required for the ASC. 15. Can you show us where we find a list of our patients? PCPs are mailed a patient roster list each month. Please refer to Member Tracking Information in PAP 611 for more information about patient rosters. 16. Where can we find a list of alpha prefixes for QHP members? PAP 102 contains a list of all alpha prefixes. This list also indicates whether a plan was purchased on or off the healthcare exchange. You may also find examples of ID cards by selecting the 2017 Qualified Health Plans link on the right side of the main page of the provider portal. Select your region from the state map and examples of ID cards will be listed. 17. Where do we sign up for JIVA, the online referral tool? If you have a username and password for the provider portal, you already have access to the JIVA system to enter and/or view referrals.

6 18. For x-ray or lab claims, whose name should appear in box 17? For x-ray or lab claims, the name of the ordering provider, regardless if it s the PCP or specialist, is required in box 17. Only referral-required specialty services need the name of the referring PCP and their NPI in box 17 or 17b of the CMS1500 claim form. For more information, please review PAP For a list of services that do not require a referral, select here. 19. I do prior authorizations for multiple physicians and offices for their patients to be sent to a facility for diagnostic testing. Do I or the facility need to be concerned if the patient is being sent from a specialist that there is a referral in place for that specialist? No. A specialist may refer a patient to any facility for diagnostic testing as long as that facility is within the patient s network.if the facility that patient needs is out-of-network, then a referral from the PCP would be required. If the diagnostic testing or imaging requires prior authorization, it is the responsibility of the ordering provider to obtain that prior authorization prior to services being rendered. 20. When looking at authorization status, does processed mean the referral was approved? When viewing the status of a referral, the term processed means that a determination has been made. To review the determination status, select the reference ID or OP under episode type and refer to Authorization Details for the approved or denied status. 21. Are claims processed as member liability or provider liability if referrals or prior authorizations are not obtained? If no referral is obtained for an in-network specialist, services will process at the allowed rate, and benefits may apply to the patient s out-of-network benefit. If no referral is obtained for an out-of-network specialist, services will process at the allowed rate and will apply to the member s out-of-network benefit. If a prior authorization is not obtained for in-network services, benefits will process as provider liability. 22. Do the True Blue Medicare Advantage plans need referrals? No. The information we are providing in these webinars only applies to the individual Qualified Health Plans, also known as the Affordable Care Act (ACA) plans. Referrals are not required for True Blue Medicare Advantage plans, the commercial PPO plans or Traditional plans.

7 23. We have many patients who live in Idaho but deliver their babies in Wyoming, which is out-of-network. Patients are telling us that Blue Cross of Idaho is requiring them to obtain a gap referral for this hospital. How do we do this? Is it an inpatient referral? If so, how would we know an admission date and how far in advance does this need to be done? In an instance like this, a gap referral would be required if the patient must go out-ofstate for their delivery, even though maternity services would not normally require a referral. The patient s designated PCP will need to enter a gap referral for the out-ofnetwork facility, following the same steps they would as if submitting a gap referral for a specialist. Please include notations explaining the circumstances as to why services are being requested for an out-of-network facility. Without an approved gap referral, facility charges will apply to the patient s out-of-network benefits regardless of the performing provider s network or referral status. Regardless of referral, maternity admission notification must be submitted within 24 hours of the admission or by the end of the next working day after admission on a weekend or legal holiday. For more inpatient notification information, please refer to PAP Where are the weekly webinar FAQs posted? All the questions asked during our weekly webinars and their answers are posted to a link on the main page of the provider portal titled 2017 QHP Educational Webinars- Weekly FAQs. This is located under the Important Announcements heading and is right below the webinar invite section. Each week s FAQs are usually posted to the provider portal by Wednesday of the following week. 25. Are these referrals only necessary for Blue Cross of Idaho plans obtained through the healthcare exchange or do the plans offered through employers also need referrals? Referrals are required for any individual QHP plan regardless of whether it was purchased through the healthcare exchange, through a broker or through our Blue Cross of Idaho shopper s website. Referrals are not required for commercial PPO plans offered through employers. 26. Are facilities required to have their own referral? Facilities are not required to have their own referral as long as they are within the patient s network. Out-of-network facilities will need a gap referral from the PCP. This can be done by following the same steps they would as if submitting a gap referral for a specialist and include notations explaining the circumstances why services are being requested at an out-of-network facility. Without an approved gap referral, facility charges will apply to the patient s out-of-network benefits regardless of the performing provider s network or referral status.

8 27. We have a patient whose network is Hometown North. Per the Provider Directory, it shows the patient s preferred PCP is contracted with Kootenai Care Network but not the Hometown North network. Will a referral request be considered out-of-network? A patient may only select a PCP that is contracting with their specific network. In this case, a patient in the Hometown North network would not have the option to select a PCP in the Kootenai Care network. If this patient needs to be referred to an out-ofnetwork specialist, then an approved gap referral would be required for the patient to receive in-network benefits. 28. We are an ASC and if we need a referral or authorization, does our name need to be on the referral and/or authorization for it to be valid for us? If you are within the patient s network, your ASC will not need its own separate referral. If, however, you are serving a patient that is outside of your network, the patient s PCP would also have to issue a referral for your facility. If the services being performed require prior authorization then the prior authorization would need to include your ASC or facility name. 29. Where on the Blue Cross of Idaho website can we find the patient s PCP? A patient s PCP can be found by performing a member search. After logging onto the provider portal, hover over the Eligibility & Claims tab and select Member Search from the drop down menu. You will then be prompted to enter the member s last name and date of birth or enrollee ID if you have it, then select the blue Search button. You will then see a list of policies for that patient, with the most current policy being at the top of the list. From here, you may select View ID Card and an image of the member s card will open, or you may select their name and an Eligibility Information screen will then appear. If the patient has chosen a PCP by the time of your search, it will display under the Member Information heading. Remember, a patient may often change their PCP so a patient s ID card information may not be current. The Blue Cross of Idaho website will provide the most up-to-date PCP and plan information. 30. We have patients who live in the Hometown East network that are currently receiving chemotherapy at our Mountain View network facility. What do we do with them? Do we have to hold treatment until they can get an approved gap referral? If the patients that you are referring to are currently receiving active treatment, this care would fall under the provisions of Continuity of Treatment; please see PAP 1005 for more information and the definition of active treatment. In this case, patients or their providers should contact customer service to inform us of this situation so that the patient may be assigned a case manager by our Healthcare Operations department. This enables a 90- day referral to be added to the patient s plan so that their active treatment may continue to be processed at in-network benefits. A patient will then be

9 redirected to an in-network provider or facility or an approved gap referral must be obtained. 31. Podiatrists have never had to have a referral before. Do we have to have one now? If you are treating a patient that has one of the new 2017 QHP plans, then you would be considered a specialist, or a non-pcp provider, and your services would require a referral. Remember, if the patient s most current ID card says Referrals Required or if their member information on our website indicates that they have chosen a QHP plan, then any care provided by a specialist requires a referral from their PCP. 32. We just tried to access the online referral system (JIVA), and we are receiving a message that says that our browser is not compatible. What does this mean? At this time due to system limitations, the JIVA system is only compatible with Internet Explorer 9 or 10, Google Chrome, or Firefox browsers. If you are using Internet Explorer 11 or higher, you may also try hovering over the white gear-shaped icon in the very top right of your screen and select Compatibility View Settings from the dropdown list. This will open another small screen and bcidaho.com should appear in the section titled Add this website. Select Add and this will move bcidaho.com to the window below titled Websites you ve added to Compatibility View. You may then close this window and then try using JIVA again. There is also a Troubleshooting article in red font on the main page of our provider portal, right above the Important Announcements heading that can provide additional assistance. 33. Some of our QHP patients have not yet picked a PCP. Is there a grace period offered to patients while they are deciding on one? If patients have not yet picked a PCP, how can specialists obtain referrals? Yes but ONLY for the month of January. Patient who have not selected a PCP will be able to notify Blue Cross of Idaho of their PCP choice and the PCP selected will be retro-effective for that patient to January 1, Beginning in February, patients who have not notified Blue Cross of Idaho of their PCP of choice will be auto-assigned one based on their geographical location and claims history. No referrals may be issued until a patient has been assigned a PCP. A patient may logon to the member portal to view and update their PCP or they can contact customer service and let them know of their PCP choice. 34. Can you please further clarify oncology services? Is it the specialist that needs the referral or the specialist and the facility that administers chemotherapy that needs a referral? In the case of oncology services, the oncologist would need a referral regardless if they were in or out-of-network; if the facility administering the chemotherapy is in the patient s network, no additional facility referral would be required. However, if the

10 chemotherapy services required prior authorization, the facility that would be administering those chemotherapy services would need to be included in the prior authorization request. 35. We are an urgent care and family practice office that is located in Madison County and therefore are in the Hometown East network. When searching our facility in the provider directory, it shows that we accept Hometown East and Mountain View networks. Does that mean we can accept patients from either network without a referral? Family Practice Services: You may only see patients with the Hometown East network without a referral for family practice services, as family practice is a primary care provider type that does not require referrals when within the network. You will need to obtain a gap referral for patients with the Mountain View network from their designated Mountain View. Urgent Care Services: Urgent care services, when billed with Place of Service 20 do not require a referral regardless of the patient s network. 36. Are these webinars recorded and will they be available to view online at a later time? Each webinar is recorded and a copy of the recording will be made available upon request to those who have attended. To request a copy of the webinar, please reply to either your invite to the WebEx or to the survey request sent at the end of each week. Special Reminder: The changes discussed above only apply to the Affordable Care Act (ACA) plans purchased through the healthcare exchanges, insurance brokers, or through the shopper s page on the Blue Cross of Idaho website for individual members and their family. Large commercial insurance plans that are furnished through employer groups such as Albertson s or Simplot for example, will not be affected by these changes.