2016 Benefit Update Meeting

Transcription

1 2016 Benefit Update Meeting Presented by Provider Relations & Education #2016providerworkshop

2 Agenda Welcome & Introductions Teosha Harrison Affordable Care Act (ACA) and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools International Classification of Diseasaes-10 (ICD-10) Provider Credentialing Additional Provider Reminders Closing Avalon is an independent company that provides benefit management services on behalf of BlueCross. Note: Contents are subject to change and are not a guarantee of payment. 2

3 Welcome & Introductions Our Mission is to serve as liaisons between BlueCross, BlueChoice and the health care community to promote positive relationships through continued education and problem resolution. 3

4 Welcome & Introductions Brian Butler Senior Director Teosha Harrison Manager, BlueCross & BlueChoice Shay Looker Manager, BlueChoice Medicaid Jada Addison Provider Advocate Elizabeth Duvall Provider Advocate Tom Ingram Provider Representative Jon Keith Provider Representative Shamia Gadsden Provider Advocate Ashlie Graves Provider Advocate Donese Pinckney Provider Representative Donna Thompson Provider Representative Mary Ann Shipley Provider Advocate Contessa Struckman Provider Advocate Sandy Sullivan Provider Advocate Sharman Williams Provider Advocate Bunny Thomas Provider Advocate Jamie Self Provider Relations Assistant The Provider Relations teams are here for you! Contact your county s designated consultant for training requests. 4

5 Welcome & Introductions 5

6 Welcome & Introductions Provider Contracting Tiesha Williams Ancillary and Hospital Contracting Scott Crisler

7 Welcome & Introductions Brian Butler Sr. Director, BlueCross Tammy Stephens Director, BlueChoice Brenda Bethel Director Jameela Jones Manager James Stone Manager Mark Austin Manager Tammy Ross Manager Marcelette Pearson Manager The Provider Services teams are essential to the service we give to our providers. 7

8 Welcome & Introductions 2016 Benefit Update Meeting Acknowledgements ony Salvati and Michele DeCaprio Kathy Wade and Kerri Fritsch Natalie Johnston Ansley Lee, Donyale Springs, Pamela Trapp National Imaging Associates (NIA) Avalon Healthcare Solutions Companion Benefit Alternatives (CBA) Patient Center Medical Home Representatives from NIA is an independent company that provides utilization management services on behalf of BlueCross. CBA is a separate company that manages behavioral health and substance abuse benefits for BlueCross Disease Management Corporate Quality BlueChoice HealthPlan Medicaid 8

9 Welcome & Introductions Webinars: We offer online presentations of various education topics each month. Newsletters and Bulletins: BlueNews for Providers is available monthly and we post provider updates in the Provider News section of both websites. Regional Workshops: Workshops on corporate initiatives are presented throughout the year. Direct Contact and Support: You may reach our internal and external advocates by calling or by at Reports: monthly, and upon request, providers receive Gaps in Care (GIC) reports, Provider Report Cards, and even pending claim reports. On-site Visits: Upon request we will visit your office to train your staff on our business processes. 9

10 Agenda Welcome & Introductions ACA and Exchanges Bunny Thomas Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 10

11 Affordable Care Act (ACA) and Exchanges Essential Health Benefits Benefits include services in 10 categories: 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Habilitative and rehabilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10.Pediatric services, including vision care 11

12 ACA and Exchanges For more Information on ACA Benefits We have three medical policies that address ACA preventive benefits. or You can also refer to our Preventive Care Guide for details about applicable ACA preventive benefits. We will continue to add or update information as we get new regulations or further guidance from the federal government. 12

13 ACA and Exchanges BlueCross Exchange Plans: Small Group Plans BlueCross offers plans to businesses with two to 50 employees. These plans use the preferred provider organization (PPO) Network. Alpha Prefixes ZCV Small Group Private ZCR Small Group FFM 13

14 ACA and Exchanges BlueCross Exchange Plans: Individual Plans BlueEssentials SM is a line of individual plans BlueCross offers. The network name indicates that the Blue Essentials Network is being used. This network is unique to these plans. Alpha Prefixes Members do not have out-of-network benefits. ZCU Individual Private ZCF Individual FFM ZCQ Individual FFM (Multi-state Plan) 14

15 ACA and Exchanges 2016 BlueEssentials Benefit Examples Gold 2 Silver 4 Bronze 1 DEDUCTIBLES Individual Deductible $800 $2,200 $6,000 Family Deductible $1,600 $4,400 $12,000 SERVICES Office Visits $15 primary care physician (PCP), $40 specialist $30 PCP, $50 specialist $80 PCP on first four visits then deductible and 40% coinsurance $125 specialist Inpatient Facility Services Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 40% coinsurance Outpatient Facility Services Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 40% coinsurance Emergency Room $300 copay, then deductible, then 30% coinsurance $300 copay, then deductible, then 30% coinsurance Deductible then 40% coinsurance Mental Health Deductible then 30% coinsurance Not applicable Deductible then 40% coinsurance COINSURANCE MAXIMUM Individual-Network $4,000 $6,850 $6,850 Family-Network $8,000 $13,700 $13,700 15

16 ACA and Exchanges Beginning January 1, 2016, each BlueEssentials individual plan will include limited dental and limited vision benefits for all members not just children. Vision services are available through VSP* and include: One exam per benefit period with a $20 copayment for a VSP provider (adults 20 or older). One exam per benefit period with a $25 copayment (members 19 or younger) Preventive dental benefits include: One exam every six months ($27 allowance first visit and $20 on the second) One cleaning every six months ($40 allowance for adults 20 or older and $31 for children) *VSP is an independent company that offers eyecare benefits and services on behalf of BlueCross plans. 16

17 ACA and Exchanges BlueCross is adding a Wellness Plus benefit for 2016 Exchange plans (small group and BlueEssentials) that provides an additional benefit toward preventive screenings. This benefit applies towards preventive services and screenings that are not covered 100 percent under the United States Preventive Service Task Force (USPSTF) guidelines. Individual Plans (BlueEssentials) - $ Small Group Plans - $ (optional) Examples of such services include CBC testing, vitamin D tests, and chest x-rays. 17

18 ACA and Exchanges BlueCross Exchange Plans: Benefits and Features To view the benefits and features of each BlueEssentials Plan, visit 18

19 ACA and Exchanges BlueChoice Exchange Plans: Small Group Plans Business Advantage plans are a line of small group plans BlueChoice offers to businesses with two to 50 employees. These plans use the existing BlueChoice Commercial Network. Alpha Prefixes ZCL Small Group Private ZCG Small Group FFM 19

20 ACA and Exchanges BlueChoice Exchange Plans: Individual (Non-Commercial) Plans BlueOption SM is a line of individual plans BlueChoice offers The network name indicates that the Blue Option Network is being used. Alpha Prefixes ZCJ Individual Private ZCX Individual FFM Members do not have out-ofnetwork benefits. 20

21 ACA and Exchanges 2016 Blue Option Benefit Examples Gold 800 Silver 400 Bronze 4500 DEDUCTIBLES Individual Deductible $800 $400 $4,500 Family Deductible $1,600 $800 $9,000 SERVICES Office Visits $20 PCP, $50 specialist 50% coinsurance for PCP and specialist $45 PCP, deductible then 50% coinsurance Inpatient Facility Services $300 copay, then deductible, then 30% coinsurance 50% coinsurance $300 copay, deductible then 50% coinsurance Outpatient Facility Services 30% coinsurance 50% coinsurance Deductible then 50% coinsurance Emergency Room $300 copay, then deductible, then 30% coinsurance 50% coinsurance $300 copay, deductible then 50% coinsurance Mental Health 30% coinsurance 50% coinsurance Deductible then 50% coinsurance COINSURANCE MAXIMUM Individual-Network $3,500 $6,600 $6,850 Family-Network $7,000 $13,200 $13,700 21

22 ACA and Exchanges Take a moment to check out all the available plans on 22

23 Covered Drug List ACA and Exchanges You can review our 2016 Covered Drug List for both BlueCross and BlueChoice Exchange plans on our websites. Caremark* handles prior authorization questions about: Step therapy Formulary exceptions *Caremark is an independent company that manages all specialty pharmacy drug benefits on behalf of BlueCross and BlueChoice. 23

24 Utilization Management ACA and Exchanges Types of service or treatment that require authorization include: Hospital admission, including maternity notifications Skilled nursing facility (SNF) admission Continuation of a hospital stay (remaining in the hospital or SNF for a period longer than was originally approved) for a medical condition Outpatient chemotherapy or radiation therapy (through NIA) Outpatient hysterectomy or septoplasty Home health care or hospice services Certain labs (through Avalon) Durable medical equipment, when the purchase price or rental is $500 or more Admissions for habilitation, rehabilitation and/or human organ and/or tissue transplants Treatment for hemophilia Mental health and substance use disorders Certain prescription drugs and specialty drugs Advanced radiological services (through NIA) Cosmetic procedures 24

25 ACA and Exchanges Reminder: Maternity benefits vary by plan. Some Plans have a one-time copay for maternity care while others apply a deductible and coinsurance. Continue to bill global maternity the same as commercial products. Plan Name 2016 Prenatal and Postnatal Care Delivery and All Inpatient Services Gold 800 $50 copay first visit $300 copay, deductible and 30% coinsurance Silver % coinsurance 50% coinsurance 25

26 Transition of Care Form ACA and Exchanges We cover out-of-network providers for emergency care only. In certain situations, individual exchange plan members may receive treatment from an out-of-network physician. If a physician is not in the individual Exchange Network and a member has a condition for which he or she is under that physician s care, and he or she wants to continue with that physician for a duration the transition of care form is necessary. The member must complete the request prior to services and the request must be approved in order to be covered. The form is on our websites. 26

27 Helpful Resources Top 10 Reminders ACA and Exchanges Health Insurance Marketplaces (Exchanges) presentation ID Card Guide Frequently Asked Questions BlueEssentials Plans Blue Option Plans 27

28 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) Jada Addison State Health Plan Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 28

29 Federal Employee Program (FEP) Standard Plan Basic Plan 29

30 Federal Employee Program (FEP) Standard Option Deductibles Individual $350 $350 Self-Plus One Not applicable $700 Family $700 $700 Services Office Visits $20 PCP copay $30 Specialist copay $25 PCP copay $35 Specialist copay Outpatient Facility Services 15% Coinsurance 15% Coinsurance Emergency Room 15% Coinsurance 15% Coinsurance Catastrophic Maximums Individual (Network) $5,000 $5,000 (Preferred) Self-Plus One (Network) Not applicable $10,000 (Preferred) Family (Network) $6,000 $10,000 Individual (OON) $7,000 $7,000 Self-Plus One (OON) Not applicable $14,000 Family (OON) $8,000 $14,000 30

31 Federal Employee Program (FEP) Standard Option Catastrophic Out-of-Pocket Maximum Self Plus One Self and Family Not applicable All family members required to satisfy the maximum, in combination, before any member s claims were no longer subject to associated member cost-sharing amounts for the rest of the year When one family member reaches the out-of-pocket maximum ($5,000 for Preferred or $7,000 for a combination of Preferred and Non- Preferred) during the calendar year, that member s claims will no longer be subject to associated member cost-sharing amounts for the rest of the year 31

32 Federal Employee Program (FEP) Services Standard Option Office visits, physical therapy, speech therapy, occupational therapy, cognitive therapy, vision services, and foot care services performed by Preferred primary care providers or other health care professionals $20 copay per visit $25 copay per visit Office visits, physical therapy, speech therapy, occupational therapy, cognitive therapy, vision services or foot care services performed by Preferred specialist Professional mental health and substance abuse services by Preferred provider $30 copay per visit $35 copay per visit $20 copay per visit $25 copay per visit Manipulative Treatment by Preferred provider $20 copay per visit $25 copay per visit 32

33 Federal Employee Program (FEP) Standard Option Services Inpatient admission to a Preferred hospital $250 per admission copay $350 copay for unlimited days Inpatient admission to a Nonmember hospital Outpatient observation services by Preferred facility $350 per admission copay plus 35% of the plan allowance for Member and Non-member providers Calendar year deductible and 15% coinsurance when billed by a Preferred facility $450 copay for duration of services, plus 35% of the Plan allowance and any remaining balance after our payment $350 copay for the duration of services Outpatient observation services by Non-member (out-of-network) facility 35% coinsurance when billed by a non-member facility $450 copay for duration of services, plus 35% of the Plan allowance and any remaining balance after our payment 33

34 Federal Employee Program (FEP) Standard Option Services Continuous Home Hospice care by Preferred providers $250 per episode copay $350 per episode copay Continuous Home Hospice care by Member or Non-member providers $350 per episode copay $450 per episode copay; for nonmember providers, member is responsible for 35% of the plan allowance, plus any remaining balance after our payment along with $450 per episode copay 34

35 Federal Employee Program (FEP) Basic Option Deductibles Individual $0 $0 Self-Plus One Not applicable $0 Family $0 $0 Services Office Visits $25 PCP copay $35 Specialist copay $30 PCP copay $40 Specialist copay Outpatient Facility Services $100 copay $100 copay Emergency Room $ 125 copay $125 copay Catastrophic Maximums Individual (Network) $5,500 $5,500 Self-Plus One (Network) Not applicable $11,000 Family (Network) $7,000 $11,000 Individual (OON) No coverage out of network No coverage out of network Self-Plus One (OON) Not applicable No coverage out of network Family (OON) No coverage out of network No coverage out of network 35

36 Federal Employee Program (FEP) Basic Option Catastrophic Out-of-Pocket Maximum Self Plus One Not applicable Self and Family All family members required to satisfy the maximum, in combination, before any member s claims were no longer subject to associated member cost-sharing amounts for the rest of the year When one family member reaches the out-of-pocket maximum ($5,500 for Preferred) during the calendar year, that member s claims will no longer be subject to associated member cost-sharing amounts for the rest of the year 36

37 Federal Employee Program (FEP) Basic Option Services Office visits, reproductive services, allergy care, treatment therapies, physical therapy, speech therapy, occupational therapy, cognitive therapy, hearing services, vision services, foot care services, alternative treatments or diabetic education by Preferred primary care providers or other health care specialists $25 copay per visit $30 copay per visit Office visits, reproductive services, allergy care, treatment therapies, physical therapy, speech therapy, occupational therapy, cognitive therapy, hearing services, vision services, foot care services, alternative treatments or diabetic education by Preferred specialists or other health care specialists $35 copay per visit $40 copay per visit 37

38 Federal Employee Program (FEP) Basic Option Services Mental health care and substance abuse services by Preferred providers $25 per visit $30 copay per visit Manipulative treatment services by Preferred providers $25 copay per visit $30 copay per visit Home nursing visits by Preferred providers $25 copay per visit $30 copay per visit Outpatient observation services by Preferred hospital or freestanding ambulatory facility $100 per day per facility $175 per day up to a maximum of $875 38

39 Federal Employee Program (FEP) Standard and Basic Option Services Ultrasound for abdominal aortic aneurysm Osteoporosis screening Hepatitis B screening for adults and adolescents, age 13 and over Low-dose aspirin Fluoride varnish Test available to all adult members once per calendar year Available for women age 60 and older once per calendar year Benefits not available Benefits not available Benefits not available Limited to one test per lifetime for adults age 65 to 75 Available for women ages 50 to 65 that have increased risk based on family history or women 65 and older Available once per calendar year Available for adults, and for adolescents, age 13 and older Available as a preventive medication for pregnant women who are at risk for preeclampsia Available up to two per calendar year for children through age 5, when administered by a primary care provider Allergy care and prescription drug benefits Benefits not available Available for specific FDA-approved drugs for sublingual therapy desensitization 39

40 Federal Employee Program (FEP) Standard and Basic Option Services Inpatient MHSA services provided at an accredited residential treatment center (RTC) Benefits only available to Standard Option members with primary Medicare Part A coverage Benefits available for treatment of medical, mental health, and/or substance abuse conditions Requires preliminary treatment and discharge plan developed Has to be agreed upon by member, case manager and RTC prior to admission Pre-authorization is required Outpatient dialysis services Plan allowance was equal to the billed charge for patient dialysis services performed by Nonmember facilities Local Plan allowance used as our Plan allowance when performed by Non- Member facilities 40

41 Federal Employee Program (FEP) Standard and Basic Option Services Bariatric surgery Outpatient facility expenses reduced when performed at a BDC for laparoscopic gastric banding surgery. Pre-surgical requirements apply. Standard option ($100 per day per facility) / Basic option ($25 per day per facility) Must pre-certify and verify facility designation as BDC Now expanded to include laparoscopic gastric stapling surgical procedures Standard option ($100 per day per facility) / Basic option ($25 per day per facility) Must still pre-certify and verify facility designation as BDC 41

42 Federal Employee Program (FEP) Standard and Basic Option Services *BRCA testing Family history criteria expanded to include both breast and fallopian tube cancer as well as breast and peritoneal cancer Genetic counseling and evaluation services are required before testing (when performed as a preventive service) Prior approval is required for preventive and diagnostic testing Testing is available for members (18 and over) when certain criteria is met BRCA1 and BRCA2 testing available for individuals 18 and over who are from a family with known BRCA1/BRCA2 mutation Includes testing for members who have a personal history of breast, ovarian, fallopian tube, peritoneal, pancreatic and/or prostate cancer, who have not received testing, when genetic counseling and evaluation supports BRCA testing Includes testing for large genomic rearrangements in BRCA1 and BRCA2 genes Prior approval is required for preventive and diagnostic testing and members have to receive genetic counseling *Additional requirements apply Intensity modulated radiation therapy (IMRT) services Pre-authorization is required for services related to the treatment of anal cancer No pre-authorization required for services related to the treatment of anal cancer 42

43 Federal Employee Program (FEP) Standard and Basic Option Wellness Benefits for Members Online Health Coach goals Eligible for up to $35 in rewards upon completion of Blue Health Assessment (BHA) Goals are exercise, nutrition, weight management, stress, and emotional health $120 in rewards ($50 for BHA and $40 for each goal) available to members who achieve three Online Health Coach goals New goals are heart disease, heart failure, COPD and asthma Blood pressure monitor Available to members who were eligible and enrolled in the Plan s Coronary Artery Disease (CAD) Management Program Available to members with high blood pressure who complete the BHA Available every two years through Hypertension Management Program 43

44 Federal Employee Program (FEP) Standard and Basic Option Wellness Benefits for Members Pregnancy Care Incentive Program Not available Available for pregnant members 18 and over who receive prenatal care in the first trimester of their pregnancy Must complete BHA Must enroll in My Pregnancy Assistant Must submit a copy of the provider s medical record documenting the prenatal care visit Members can earn Pregnancy Care Box and $75 toward a qualified health account 44

45 Federal Employee Program (FEP) Standard and Basic Option Reminder Wellness Benefits for Members Diabetes Management Incentive Program Must complete BHA Available for members age 18 and over Up to $75 in rewards 45

46 Federal Employee Program (FEP) Updates and Reminders FEP member information is now available on My Insurance Manager SM FEP Blue Website is FEP telephone number is

47 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Jada Addison Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 47

48 State Health Plan State Standard Plan State Savings Plan MUSC Health Plan 48

49 Deductibles Copays State Health Plan Standard Plan Individual $445 Family $890 Office Visits $12 Outpatient Facility Services $95 Emergency Room $159 Coinsurance Maximums Individual (Network) $2,540 Family (Network) $5,080 Individual (OON) $5,080 Family (OON) $10,160 No changes for

50 Deductibles Copays State Health Plan Savings Plan Individual $445 Family $890 Office Visits $12 Outpatient Facility Services $95 Emergency Room $159 Coinsurance Maximums Individual (Network) $2,400 Family (Network) $4,800 Individual (OON) $2,400 Family (OON) $9,600 No changes for

51 State Health Plan State Standard members who have services rendered at PCMH will have $12 per occurrence physician office copay waived and member coinsurance will be calculated at 10 percent instead of 20 percent for Standard members only No member cost share for routine and diagnostic colonoscopies as allowed by USPSTF performed by participating provider No member cost share for adult immunizations as recommended by the Centers for Disease Control and Prevention (CDC) performed by participating provider 51

52 State Health Plan No member cost share for: Prescription tobacco cessation products Diabetes education performed by participating provider Contraceptives to subscribers and covered spouses 52

53 Additional Plan Information State Health Plan Updates to Precertifications through My Insurance Manager for State Health Plan: At the time of pregnancy notification, choose type of service non procedure and location-home and then search for P-pregnancy notification At the time of admission for delivery, the facility will choose type of service-procedure and location- Inpatient, and then search for Vaginal Delivery or C-Section Delivery 53

54 State Health Plan Additional Plan Information (cont d) Updates to Pharmacy Effective January 1, 2016, Express Scripts will administer State Health Plan prescription drug benefits. The formulary list is available at The SCRIPTS database is maintained by South Carolina Department of Health and Environmental Control (DHEC), which is mandatory for prescribers of opioids. SCRIPTS utilization should be a part of every patient s initial evaluation and subsequent monitoring and is considered the standard of care. Express Scripts is an independent company that manages pharmacy benefits on behalf of BlueCross. 54

55 State Health Plan Additional Plan Information SHP began covering shingles vaccinations for individuals age 60 and over. Flu vaccinations are now covered for all State Health Plans with no member cost share. 55

56 State Health Plan State Health Plan member information is available on My Insurance Manager State Health Plan Website is State telephone number is

57 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Sharman Williams Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 57

58 Upstate 1 Networks Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks BlueCross and BlueChoice have partnered with MyHealth First Network (MyHFN) to offer an array of small group Exclusive Provider Organization (EPO) or narrow network products beginning January 1, Created to serve small employers (two to 50 employees) in six Upstate counties: Abbeville Greenville Greenwood Laurens Oconee Pickens MyHFN is a clinically integrated narrow network of providers who collaborate and share a common goal of improving health outcomes, reducing health care costs and enhancing the patient experience. 58

59 Upstate 1 Networks Blue Exclusive Upstate 1 BlueCross ID Card Exclusive Provider Organization (EPO) 59

60 Upstate 1 Networks BusinessADVANTAGE Select Upstate 1 BlueChoice HealthPlan ID Card Exclusive Provider Organization (EPO) 60

61 Upstate 1 Networks BusinessADVANTAGE Select Upstate 1 High Deductible Health Plan (HDHP) BlueChoice HealthPlan ID Card Exclusive Provider Organization (EPO) 61

62 Upstate 1 Networks Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks EPO networks consist of these various provider types in the Upstate region of South Carolina: Ancillary Providers Doctors Care (All SC locations EXCEPT those within the six county EPO network and Newberry County) Pharmacies Caremark s list of national and South Carolina pharmacies Clinics Hospitals Primary Care Providers CVS Minute Clinics (All SC locations) MD360 Express Medical Care Specialists Important: There are no out-of-network benefits, except for true emergency services provided in an emergency room setting. 62

63 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) Sharman Williams BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 63

64 Preferred Blue (PPO) ID Cards 64

65 Preferred Blue (PPO) 2016 New Network Product: Group Name Business Blue Exclusive Upstate New Groups: Group Name Aiken County Comporium Communications Ingevity Tire Centers United Sporting Companies Roper Hospital Southern Management Lexington Medical Center JJD ZCW FQC INV THI To be assigned FRA To be assigned ZCW Alpha Prefix(es) Alpha Prefixes 65

66 Preferred Blue (PPO) BlueCross BlueShield of Illinois: Boeing Clinically Integrated Network 66

67 Preferred Blue (PPO) 2016 New Network Product: Group Name Business Blue Exclusive Upstate New Groups: Group Name Aiken County Comporium Communications Ingevity Tire Centers United Sporting Companies Roper Hospital Southern Management Lexington Medical Center JJD ZCW FQC INV THI To be assigned FRA To be assigned ZCW Alpha Prefix(es) Alpha Prefixes 67

68 Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina Sharman Williams BlueChoice HealthPlan Medicaid Agenda BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 68

69 BlueChoice HealthPlan ID Cards Product Name Network Name Visit on the Doctor & Hospital Finder page, to view BlueChoice HealthPlan products and networks. 69

70 BlueChoice HealthPlan 2016 New Network Product: Group Name BusinessADVANTAGE Select Upstate 1 Products Not Offered in 2016: Plan/Product Name MyChoice: Open Access MyChoice: Individual Coverage MyChoice: Open Access HDHP MyChoice: Individual Coverage HDHP MyChoice: Open Access Value Plan CarolinaADVANTAGE MyChoice (Primary Choice HMO) CarolinaADVANTAGE HDHP Current members can remain in these Plans. Alpha Prefix Group Name Plan/Product Name ZCC Lexington Medical Center MyChoice (Primary Choice HMO) Current members will have new coverage in ZCI Alpha Prefixes Always ask for a current ID card to verify eligibility and benefits. 70

71 BlueChoice HealthPlan These services no longer require prior authorization when performed by a PCP: Procedure Colonoscopy Continuous overnight pulse oximetry Excision of nail CPT/HCPCS Code(s) Flexible sigmoidoscopy 45300, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45339, Iron injection* J1750 Paring or cutting of benign lesions Spirometry 94010, 94014, 94015, 94016, 94060, 94070, 94375, Removal skin tags U/S bone density measurement (peripheral) *Not covered for Health Insurance Marketplace (Exchanges) Plans A list of these services can be found in the BlueChoice Provider Manual and the Provider News page of 71

72 BlueChoice HealthPlan Diabetic members can receive a routine eye exam (office visit and refraction only), covered at 100 percent of allowable charges. Members must use a Physician EyeCare Network provider and the self-referral authorization form. This benefit is valid for one visit with the following codes: New Patient: Established Patient: Refraction: ICD-10 Primary Diagnosis Codes: E10.9, E11.0, E11.9, E10.65, E11.65, E11.8, E11.311, E11.319, E11.36, E11.39 Physician EyeCare Network is an independent company that offers vision care services on behalf of BlueChoice. 72

73 BlueChoice HealthPlan Authorization is not required for Durable Medical Equipment $499 and under. Continue using for all available provider resources. 73

74 Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Network Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid Jon Keith, Donna Thompson, Tom Ingram, Donese Pinckney Agenda BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 74

75 BlueChoice HealthPlan Medicaid Who We Are BlueChoice HealthPlan Medicaid entered the South Carolina Medicaid marketplace in After seven years of dedicated service to our member and provider communities, our health plan is continuing its strong momentum. We are still growing. Our staff is dedicated to Medicaid. We are approved in all 46 South Carolina counties. We have approximately 80,000 members. We have approximately 12,363 providers in our network. We have 59 participating hospitals in our network. 75

76 BlueChoice HealthPlan Medicaid Tools to Assist You Membership Reports We update these reports monthly for our PCPs. They identify all members we assign to each physician within a PCP group. These reports are available via our Provider Access, secured website. Medical Loss Ratio Reports We generate these reports on a quarterly basis for our PCPs. They indicate a cost breakdown associated with the specific practice. Emergency Room (ER) Diversion Reports We generate these reports monthly for our PCP providers. They identify those members who we assign to your physicians and who have visited the ER within the last month. The reports also indicate the member s diagnosis at the time of his or her ER visit. Gaps in Care Reports We generate these reports monthly for our PCPs. These reports identify members you need to see for well exams, immunizations, etc. 76

77 BlueChoice HealthPlan Medicaid BlueBlast SM The BlueBlast is a monthly, providerfocused newsletter. It typically includes: Important health plan updates Healthy Connections announcements Billing and claims information Frequently asked provider questions Community outreach efforts and upcoming events If you would like to begin receiving a copy of the BlueBlast electronically or via mail, please contact your Provider Relations representative. 77

78 BlueChoice HealthPlan Medicaid Contacts Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product. Website: Provider Care Center: (Verify eligibility, benefits, claims status, general questions, etc.) Voice: Monday to Friday: 8 a.m. to 6 p.m. Fax: or TTY: Hour Nurseline: (Registered nurses provide health information on illnesses and options for accessing care, including emergency services, if applicable.) Voice: TTY:

79 BlueChoice HealthPlan Medicaid Contacts Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product. Utilization Management: [Prior authorization (PA) and hospital/facility admission notification] Voice: Monday to Friday: 8 a.m. to 5 p.m. Fax: Case Management: Care coordination and Women Infant and Children (WIC) information: Voice: Monday to Friday: 8 a.m. to 5 p.m. WIC: hours a day, seven days a week 79

80 BlueChoice HealthPlan Medicaid Contacts Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product. Disease Management: (Programs for chronic conditions) Voice: TTY: Express Scripts, Inc.: Voice: Monday to Friday: 8 a.m. to 9 p.m. Fax: Saturday to Sunday: 8 a.m. to 6 p.m. Vision Service Plan (VSP): Voice: TTY: Monday to Friday: 8 a.m. to 10 p.m. 80

81 BlueChoice HealthPlan Medicaid Pharmacy Network Effective 11/1/15 we have a new pharmacy network. This network excludes Walgreens. Pharmacies still in network: BI-LO CVS K-Mart Kroger Longs Publix Rite Aid Target Walmart 81

82 BlueChoice HealthPlan Medicaid Most Common Denials Ineligible Members at the Time of Service Preferred tool for checking eligibility. This portal provides information on What MCO covers the member. The health plan anniversary date. The anniversary date indicates when a member should renew. The beneficiary s third party payers, if he or she has additional health coverage. 82

83 BlueChoice HealthPlan Medicaid Most Common Denials Ineligible Members at the Time of Service Or contact SCDHHS Provider Care Center at to request access to this site. 83

84 BlueChoice HealthPlan Medicaid Identification (ID) Card In addition to the BlueChoice HealthPlan Medicaid member ID card, members are required to carry their SCDHHS-issued Healthy Connections ID cards. 84

85 BlueChoice HealthPlan Medicaid Most Common Denials Out-of-Network (OON) Claims Denial The top OON denial reasons include: Claims filed with no rendering NPI in block 24J. Billing with a non-credentialed physician/practitioner as the rendering Billing with a physician assistant as the rendering Claims filed with an incorrect or no rendering NPI RHC claims filed with an incorrect or no rendering NPI Rendering NPI T1015 RHC NPI Tax ID Number Physical Address Billing NPI Number Billing Address Billing NPI Number Tax ID Number RHC Physical Address RHC NPI Number RHC Billing Address RHC NPI Number 85

86 BlueChoice HealthPlan Medicaid Most Common Denials Duplicates When we deny a claim, it isn t a good idea to refile the claim. Duplicate claims submissions will cause additional denials. If you are unsure about the reasons for your claim s denial, please contact the Provider Care Center. When submitting a hard copy corrected claim, please attach a Claims Follow Up form. You can submit this form electronically. To access this form, visit: es/bluechoice/documents/providers/claim_foll owup.pdf 86

87 BlueChoice HealthPlan Medicaid Steps to Claims Resolution Check claims status via the Web at Contact the Provider Care Center at Please remember to get the name, date and reference number of the Provider Care Center representative. If you need further assistance, you can reach out to your Provider Relations representative. 87

88 BlueChoice HealthPlan Medicaid Claims Submission Electronic Data Interchange (EDI) [Payer ID 00403] Preferred and fastest way to submit claims You can also submit corrected claims electronically through EDI To register or to submit questions, call Hard Copy Claims Submissions, Corrected Claims and Correspondence To submit a hard copy claim, corrected claim, appeal or any type of correspondence, please send mail to: BlueChoice HealthPlan Medicaid Attn: Medicaid Claims P.O. Box Columbia, SC

89 BlueChoice HealthPlan Medicaid Provider Updates Providers are now required to be enrolled directly with SCDHHS. All SCDHHS manuals have updated section 1, pages 1-10 to reflect this change. Please ensure that all of your practitioners are enrolled with SCDHHS and have been assigned a Medicaid number. SCDHHS assigns Medicare numbers 89

90 BlueChoice HealthPlan Medicaid Incentives Notice of Pregnancy (NOP) Notice of Delivery (NOD) Screening Brief Intervention and Referral to Treatment (SBIRT) Quality Incentive Program ACA Enhanced Reimbursement 90

91 BlueChoice HealthPlan Medicaid Utilization Management UM Intake Fax: Phone: Pharmacy Requests:

92 BlueChoice HealthPlan Medicaid Utilization Management Denials I have a denial, what can I do? Only the medical director issues denials and can overturn them. Read your copy of the denial letter. This contains important information about the rationale for the denial. (If the denial is based on network status, contact your provider relations representative.) A treating medical doctor (MD) should call for a peer to peer (P2P) review. The P2P review provides real-time discussion of the treatment for the member. Submit appeals by calling the Provider Care Center at There is a 90-day calendar timeframe from the date of the denial notification to file an appeal. 92

93 BlueChoice HealthPlan Medicaid Need Assistance? Our Quality Management department looks forward to partnering with you as we pursue our mutual goal of providing access to high quality care and service to members. Have questions? For HEDIS, call our Clinical Quality Management department at

94 BlueChoice HealthPlan Medicaid BlueChoice HealthPlan Medicaid In the Communities We Serve! 94

95 BlueChoice HealthPlan Medicaid Value-Added Benefits SafeLink Cell Phone Program Free phone and 350 monthly minutes Unlimited text messages Free calls to BlueChoice HealthPlan Medicaid Text messages with health tips and reminders 200 bonus minutes 100 minutes on birthday 95

96 BlueChoice HealthPlan Medicaid Value-Added Benefits Free Boys & Girls Club memberships at participating locations (does not include summer camp) Free statewide Girl Scout memberships (plus free uniform or journey book for girls K-5 th grade) Prenatal Rewards Program Free gift cards (for healthy behaviors) Free educational booklets Community baby showers Free car seat for pregnant moms (eligibility requirements apply) Free manual breast pumps 96

97 BlueChoice HealthPlan Medicaid Community Outreach Team For questions about community outreach initiatives, please contact: Daphney Addison, Outreach Specialist Sr. (PeeDee Region) Direct: David Rojas, Outreach Specialist Sr. (Upstate Region) Direct: Letitia Lindsay, Outreach Specialist Sr. (Midlands Region) Direct: Chiara Lazarus, Outreach Specialist Sr. (Low Country) Direct: Donna Williams, Marketing Officer Direct: Office:

98 2016 Benefit Update Meeting BREAK

99 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Sandy Sullivan Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 99

100 BlueCard Program Overview The BlueCard program enables Blue Plan members to get health care service benefits and savings while traveling or living in another Blue Plan s service area. The program links participating health care providers across the country and internationally through a single electronic network for claims processing and reimbursement. The BlueCard program lets you submit claims for Blue Plan members directly to your local BlueCross BlueShield of South Carolina Plan. We will be your point of contact for education, contracting, claims payment/adjustments and problem resolution. 100

101 BlueCard Program How to Identify BlueCard Members When members of Blue Plans arrive at your office or facility, be sure to ask them for their current Blue Plan membership ID cards. The ID cards may have: PPO in a suitcase logo PPOB in a suitcase logo A blank suitcase logo 101

102 BlueCard Program Home Plan The Plan that holds the patient s membership and benefits information. Responsibilities: Enrollment process, issuing ID cards and utilization management. Benefit, membership and eligibility determination. All member interactions including member service calls and education. Claim adjudication (benefit application) and creation of member EOBs. 102

103 BlueCard Program Host Plan The Plan that is local for the provider that renders services. Responsibilities: Perform provider contracting, training and education. Receive claims from local providers and price claims. Route claim information with pricing data to the Control/Home Plan. Send remittance notice and reimbursement to provider. Handle ALL provider inquiries and provider service. 103

104 BlueCard Program How Claims Flow through BlueCard This is an example of how claims flow through BlueCard. 1. Member of another Blue Plan receives services from the provider. 2. Provider submits claim to the local Blue Plan. 3. Local Blue Plan recognizes BlueCard member and transmits standard claim format to the member s Blue Plan. 4. Member s Blue Plan adjudicates claim according to member s benefit plan. 7. Local Blue Plan pays the provider. 6. Member s Blue Plan transmits claim payment disposition to the local Blue Plan. 5. Member s Blue Plan issues an EOB to the member. 104

105 Medical Records If records are requested: BlueCard Program Forward all requested medical records to BlueCross BlueShield of South Carolina within 10 calendar days. Follow the submission instructions given on the request, using the specified physical or address or fax number. Include your fax number, too. 105

106 BlueCard Program The Electronic Provider Access (EPA) Tool Enables you to use My Insurance Manager to access out-of-area members Blue Plan (Home Plan) provider portals through a secure routing mechanism to conduct electronic pre-service review. A separate sign-on is not required once you have been routed to the Home Plan landing page. The availability of electronic provider access (EPA) will vary depending on the capabilities of each Home Plan. 106

107 BlueCard Program BlueCard Precertification/Medical Policies Access via My Insurance Manager Check medical policies Get general precertification requirements for out-of-area Blue patients Get contact information to initiate precertifications 107

108 BlueCard Program BlueCard Quick Tips Request BlueCross BlueShield of South Carolina Member s Home Plan Eligibility and Benefits BLUE (2583) Prior Authorization Claim Submission Claim Status Medical Review Request (My Insurance Manager) View ID card for prior authorization contact info Not applicable Not applicable Not applicable 108

109 BlueCard Program Helpful BlueCard Education Resources BlueCard Program Provider Manual Webinar trainings Bulletins 109

110 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Sandy Sullivan Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 110

111 Where to file claims Ancillary Claims Where the specimen was collected Lab Provider OR Where the referring physician is located Durable/Home Medical Equipment Provider Where the equipment or supplies were delivered or purchased Specialty Pharmacy Provider Where the ordering physician is located 111

112 Ancillary Claims Ancillary Provider Tips It is important that you use in-network participating ancillary providers to reduce the possibility of additional member liability for covered benefits. Members are financially liable for ancillary services not covered under their benefit plan. It is the provider s responsibility to request payment directly from the member for non-covered services. Physicians should only refer patients to in-network lab processing and drawing stations. 112

113 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Kathy Wade, Kerri Fritsch Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 113

114 Avalon Healthcare Solutions The cost of health care is rising for everyone and we have an obligation to ensure that our members receive the highest quality of care at the most affordable cost. Laboratory medicine is continuing to become increasingly complex. As technology improves, the cost and utilization of these services increase. This program will assist us in ensuring appropriate testing for our members at the lowest out-of-pocket cost. We have partnered with Avalon Healthcare Solutions, a clinical services and information technology company providing comprehensive diagnostic laboratory management services to health plans. Avalon will administer a comprehensive suite of laboratory benefit management services to promote patients access to affordable, high-quality health care. 114

115 Avalon Healthcare Solutions Over 4,000 different lab tests exist, and the menu continues to increase in size, complexity and cost Over 9 billion tests are performed each year, more than any other health care procedure Lab tests are the basis for at least 70 percent of clinical decisions 30 percent of volume represents overused or medically unnecessary testing, and not ordering a test when clinically appropriate may reach the same level Nearly 3 in 4 physicians say unnecessary tests represent a serious problem 115

116 Avalon Healthcare Solutions Primary care physicians are uncertain about the appropriate test to order in 15 percent of diagnostic encounters and uncertain about interpretation of results in 8 percent of cases With 500 million primary care patient visits per year, that means 23 million times a year a primary care physician is uncertain about the appropriate use of a diagnostic test Between 15 percent and 54 percent of medical errors reported by primary care doctors are related to testing 116

117 Avalon Healthcare Solutions How Does This Program Affect Physicians? Sometimes patients may need a specialized test. We considered this issue and included specialty labs and centers of excellence within the network of laboratory providers. The centers of excellence are staffed by qualified clinical pathologists and genetic counselors prepared to answer your inquiries both before and after you perform testing. We do not qualify all laboratories. If an out-of-network laboratory services you or you have outpatient testing performed by a hospital, your patients out-of-pocket cost may be significant. To ensure the lowest cost to your patients, please send BlueCross and BlueChoice members testing to in-network laboratories only. Please note that Avalon doesn't manage services in an emergency room, observation room, surgery center or hospital inpatient setting. This change does not alter the available member benefits, but using these participating providers will result in a lower out-of-pocket cost for your BlueCross- and BlueChoicecovered patients. 117

118 Avalon Healthcare Solutions Implementation January 1, 2016: New medical policies will take effect that impact laboratory services. We will enforce preauthorization requirements for select laboratory procedures. April 1, 2016: Enhanced medical policy administration, including post-service claims edits, will go into effect. Remember to use an in-network laboratory to limit your patients out-of-pocket costs. 118

119 Avalon Healthcare Solutions RCs 1&2 Med Policy Education RCs 1&2 Effective/ RC 3 Program Announcement Claim edits implemented RC 3 Effective/ RC 4 Program Announcement RC 4 Med Policy Education RCs 1&2 Program Announcement 2015 Aug Sept Oct Nov Dec 2016 Feb Mar Apr May June July Program Intro/Prior Auth ns Webinars Prior Auth implemented Avalon partnered with BlueCross and BlueChoice to provide comprehensive laboratory benefits management services The new group of providers were added to the network to increase access to specialized testing All new and currently contracted providers, including LabCorp, Quest and other large labs, are listed in the BlueCross BlueShield of South Carolina directory 119

120 Avalon Healthcare Solutions Medical policies containing precertification elements: BCR-ALB 1 Testing for Chronic Myeloid Leukemia BRCA Cardiac Ion Channelopathies Chromosomal Microarray Cytochrome P450 Epidermal Growth Factor Receptor Familial Adenomatous Polyposis Flow Cytometry FLT3 and NPM1 Mutation General Genetic Testing Genetic Testing for Cystic Fibrosis Genetic Testing for Duchenne and Becker Muscular Dystrophy Genetic Testing for Fanconi Anemia Genetic Testing for FMR1 Mutations Genetic Testing for RET Proto-oncogene in Medullary CA of Thyroid Genetic Testing for Rett Syndrome HIV Genotyping and Phenotyping JAK2 and MPL Mutation KRAS and BRAF Li-Fraumeni Syndrome Lynch Syndrome Non-Invasive Screening for Aneuploidy Pre-Implantation Testing Prenatal Screening PTEN Hamartoma Tumor Syndrome 120

121 Avalon Healthcare Solutions Avalon developed a code matrix in an effort to help you determine when you need to contact Avalon for precertification. Code Description BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., maple syrup urine disease) gene analysis BRAF (v-raf murine sarcomaviral oncogenehomolog B1) (e.g., colon cancer), gene analysis; full sequence Full gene sequence Interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; evaluation to detect abnormal (e.g., expanded alleles) You can view this detailed matrix on our website, in the Provider section under Precertification. 121

122 Avalon Healthcare Solutions You can submit prior authorization requests by phone, fax or online. Avalon will promptly review your request for medical necessity and provide you with a timely, written decision. Telephone: Fax: It is the responsibility of the referring physician to get the authorization, however, the lab may do so if they have the necessary clinical information. 122

123 Avalon Healthcare Solutions Avalon Network The Avalon network of labs is offered as a supplement to the current BlueCross and BlueChoice networks. To verify participating labs visit our Provider Directories found on or 123

124 Avalon Healthcare Solutions Helpful Resources Lab Procedures Procedure Authorization Matrix News bulletins Avalon presentation More education to come 124

125 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Contessa Struckman Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 125

126 Quality Initiatives Our goal is to work collaboratively with physicians and hospitals to impact the health of our members and the community. Through our joint efforts to reorganize systems of care, we are working to align incentives to support evidence-based care, share best practices and improve overall health outcomes. We know that collaboration with the medical community leads to better long-term quality of life for our members and a more costeffective health care system. 126

127 Quality Initiatives OB/GYN PROVIDER PINE ST. CITY, STATE Maternity Initiatives: OB/GYN Report Cards BOI - The number of delivery claims submitted using the appropriate procedure codes and modifiers SBIRT - The number of women who delivered and received a screening and/or a referral to treatment C-Section Rate - The number of babies delivered via C-section Preterm Rate - The number of babies delivered prior to 37 weeks of gestation And other categories. 127

128 Helpful Resources Quality Initiatives Healthier Moms and Babies publication This publication gives you information about our maternity managed care programs, informs you of helpful tools to engage your patients and provides you with resources to integrate your patient care with our services. Maternity Initiatives Presentation SBIRT Form Pregnancy Notification Form OB/GYN Report Cards Maternity Initiatives FAQs 128

129 HEDIS Quality Initiatives This is a tool that measures performance in the delivery of medical care and valuable health services. The National Committee for Quality Assurance (NCQA) coordinates and administers HEDIS yearly. The Center for Medicare and Medicaid Services (CMS) uses it for monitoring the performance of health plans. The tool evaluates both physical and behavioral health clinical practice guidelines (CPG) adherence. H E D I S Healthcare Effectiveness Data and Information Set 129

130 Quality Initiatives HEDIS: How is data gathered? Annually, members are randomly selected for review based on a predetermined sample size for each measure. Data is collected throughout the year through retrospective review of services via claims information and medical records. Members who have not had a claim submitted for specific services may be selected to assess barriers and provide information to providers using Gaps in Care Reports. Certified auditors rigorously audit HEDIS results using a process designed by NCQA. 130

131 Quality Initiatives HEDIS: What is a gap in care? Care gaps occur when a member has not received valuable health services. Quality Improvement Our QI nurses will meet with you for deep dive chart reviews and techniques to closing care gaps. Your physician or practice can gain recognition for promoting good health and fighting disease. Rewarding Excellence Gaps in Care Closure Provider Relations and Education You will receive GIC Reports from your provider advocate and support in understanding this quality initiative. 131

132 Quality Initiatives Helpful Resources or Gaps in Care Reports Provider Reference Matrix Guides HEDIS Charts Compliance Companion Forms All of these tools work hand-in-hand to ensure success! Remember: we are less likely to request medical records when you submit claims with all appropriate procedure and diagnosis codes. 132

133 Quality Initiatives Helpful Resources Gaps in Care Reports ID Card Number Date of Birth Gender Quality Measure (undocumented or missed care) 133

134 Helpful Resources Available on our websites Provider Reference Matrix Guides (shown) HEDIS Charts Compliance Companion Forms (shown) Quality Initiatives 134

135 HEDIS: 2016 Timeline Quality Initiatives Mid-October 2015 Supplemental Review Process Begins Mid-January 2016 Hybrid Medical Records Review Process begins Early January 2016 Quality Nurses Onsite Scheduling Begins March 2016 Supplemental Review Process Ends May 2016 Hybrid Medical record Review Process Ends June 2016 Final Rates are Submitted and Locked 135

136 Quality Initiatives As part of CMS data validation activities, we are reviewing charts in an ongoing process seeking to make sure that our records properly reflect the clinical condition(s) of our members. Talk with patients about their current conditions during every encounter, ensure that the appropriate diagnosis code for each condition is submitted with the claim and documented in the medical record. 136

137 Quality Initiatives Patient Surveys: CAHPS C A H P S Consumer Assessment of Healthcare Providers and Systems CAHPS is a survey designed to support consumers in assessing the performance of their health plans. Asks consumers (patients) to evaluate their experiences with health care services Survey assesses the communication skills of providers, ease of access to health care services and more topics Measures a member s satisfaction with the health plan, providers, customer service, etc. 137

138 Patient Surveys: CAHPS Survey questions: Your Health Care in the Last 12 Months In the last 12 months, when you needed care right away, how often did you get care as soon as you needed? Your Personal Doctor In the last 12 months, how often did your personal doctor spend enough time with you? Quality Initiatives 138

139 Quality Initiatives Q H P E E S Qualified Health Plan Enrollee Experience Survey Patient Surveys: QHP EES QHP EES is a new consumer experience survey that assesses enrollee experience with the Qualified Health Plans (QHPs) offered through the Marketplaces (Exchanges) It was circulated nationally for the first time this year CMS-approved survey vendors administered it Asks consumers and patients to report on and evaluate their experiences with health care services in the last six months 139

140 Quality Initiatives Patient Surveys: QHP EES Survey questions: Your Health Care in the Last Six Months In the last six months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed? Your Personal Doctor In the last six months, how often did your personal doctor show respect for what you had to say? Survey information available at 140

141 Quality Initiatives Patient Surveys: How can providers influence patient satisfaction and impact survey results? Access to care and care coordination are two areas that you can significantly affect. Consider: How easy is it for my patients to get an appointment? Do I (doctor) explain things in a way my patients can understand? Refer to the Improving Patient Satisfaction for Providers publication for articles about care coordination and quality standards. 141

142 Quality Initiatives Rewarding Excellence: Hospital Program Rewards top-performing hospitals with increased payments for the quality of care they provide. Quality measures include key safety and efficiency measures, as well as patient experience. GOAL: To compensate hospitals for the quality of care provided to patients, not just the quantity of procedures performed. 142

143 Quality Initiatives Rewarding Excellence: Physician Program Support quality initiatives to improve health outcomes for members. Emphasis is based on HEDIS, STARS and Quality Reporting System (QRS) measures. Help physicians and practices succeed in preventing and closing gaps in care 143

144 Quality Initiatives Practice Organization What is a Patient-Centered Medical Home (PCMH)? Patient Experience Family Medicine Quality Measures Health Information Technology Team-based approach to health care led by a physician, nurse practitioner or physician assistant Addresses all of a patient s health care Has national recognition as a PCMH 144

145 Quality Initiatives PCMH: Why should your practice consider becoming a PCMH? Overall improved patient outcomes Increased satisfaction among physicians-staffpatients Performance-based incentives and compensation 145

146 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Ranarda Jones Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Closing 146

147 Pharmacy Management BlueCross Prescription Drug/Medicare Part D Medicare Part D (PDP product only): Has its own formulary and drug management programs Prime Therapeutics will continue as the pharmacy benefits manager (PBM) for Part D business. Plan Name Changes Pharmacy Network Enhancements Formulary Changes Other 147

148 Pharmacy Management Plan Name Changes for MedBlue Rx BlueCross Rx Value MedBlue Rx Plus BlueCross Rx Plus Same familiar phone numbers and helpful customer service staff. We will mail new ID cards prior to January. 148

149 Pharmacy Management Pharmacy Network Enhancements Preferred Pharmacy is new for 2016 for the Value plan Our preferred network includes some of the major chains as well as independents Members will have a lower cost share for prescriptions filled at a preferred pharmacy versus a standard retail pharmacy Long Term Care members will receive the preferred pharmacy copayments 84 percent of BlueCross Rx Value members currently fill their prescriptions at a preferred pharmacy 149

150 Pharmacy Management Overview of Formulary Changes BlueCross Rx Value and BlueCross Rx Plus will each use a 5 tier formulary for 2016 A given drug may be in different tiers across the two plans BlueCross Rx Value formulary Changes made but meets CMS requirements with at least two drugs covered per USP class Shifted some high-cost generic drugs to branded tiers BlueCross Rx Plus formulary Has minimal changes from 2015 formulary Drugs may be in different tiers from 2015 to 2016 Same utilization management applies to both formularies (i.e., PA, step, QL) 150

151 Pharmacy Management BlueCross Rx Value Top Formulary Removals for 2016 Nexium (brand and generic) Glyburide Levothroid (brand) Levemir Valsartan/HCTZ Lansoprazole Synthroid (brand) Livalo Oxycontin Avodart (brand and generic) Benicar & Benicar HCT Celecoxib (generic Celebrex) Bystolic Amlodipine/benazepril Dexilant Bisoprolol/HCTZ Jalyn Rabeprazole (generic Aciphex) Formulary alternatives can be found at or by using the published formulary document on 151

152 Pharmacy Management Medically Accepted Indication CMS will not allow a Part D plan sponsor to cover a medication that does not have a medically accepted indication as approved by the FDA or in CMS-supported compendia Examples include: Cialis, Lidoderm patches and oral Fentanyl Cyclobenzaprine 152

153 Pharmacy Management Part D Prescriber Regulations Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Medicare Part D may no longer cover drugs that are prescribed by physicians or other eligible professionals who are neither validly enrolled, nor opted out of Medicare. All prescribers should enroll before January 1, 2016 to allow for the processing of applications and to ensure enrollees get their prescriptions. 153

154 Pharmacy Management BlueCross Rx Value Top Formulary Removals for 2016 Documents found on Pharmacy Directory Summary of Benefits Annual Notice of Changes and Evidence of Coverage Comprehensive Formulary Coverage Determination Forms Information on filing appeals and grievances Documents found on Searchable Formulary 2016 Preferred Pharmacy Finder Prim New Order Form Coverage Determination Forms Prior Authorization Step Therapy Quantity Limits Formulary Exception 154

155 ACA Business Pharmacy Management ACA (Marketplace) products: CVS Caremark will continue as the PBM for all ACA formulary and drug management programs. The Covered Drug List is the name of the formulary list used for the ACA metal plans. A searchable version of the Covered Drug List can viewed by visiting the link, or 155

156 Pharmacy Management Overview: BlueCross & BlueChoice Commercial Pharmacy Management Update Exclusive Specialty Pharmacy Vendor Change for 2016 New Drug Management Programs under the Medical Benefit Utilization Management BlueChoice multi-tiered Prescription Drug List 156

157 Pharmacy Management Specialty Drug What are Specialty Drugs? Used to treat rare conditions that affect approximately 1 percent of the population Generally requires special storage, handling and administration Expensive treatments that range from $30K to $400,000 annually per patient Contributing to approximately 30 percent to 40 percent of overall drug costs Costs are forecasted to increase at a rate of 16 percent to 20 percent annually Ex: Orkambi Specialty drug used to treat cystic fibrosis (CF) patients who have a specific gene mutation 30,000 CF patients in the US 15,000 CF patients are candidates for treatment Improves lung function and is suspected to significantly improve life expectancy Annual ongoing cost of therapy = $300,

158 Pharmacy Management Preferred Specialty Pharmacy Effective January 1, 2016 CVS/specialty will become the preferred specialty pharmacy vendor for both BlueCross and BlueChoice commercial and ACA lines of business. CVS/specialty is a division of CVS Caremark, an independent company that provides pharmacy benefit management and specialty pharmacy services on behalf of our members health plans. Accredo will no longer be in network. Patients with refills at Accredo, that can legally be transferred, will be autotransferred to CVS/specialty on January 1. We have notified physicians and members who will be impacted by the change. CVS/specialty will also be contacting members to assist with the transition. Note: These updates do not apply to the State Health Plan. 158

159 Pharmacy Management Drug Management Programs under the Medical Benefit Effective April 1, 2016 Certain drugs administered by a provider and billed through the medical benefit will require prior authorization Providers will receive education on how to submit prior authorization requests to the plan via Novologix. All drug claims will require you to submit the NDC-11 drug code with the claim when billing for reimbursement under the medical benefit. 159

160 Pharmacy Management Drug Management Programs under the Medical Benefit A few examples of drugs that will require prior authorization under the medical benefit effective April 1, 2016 include: Remicade Rituxan Synagis Simponi Benlysta Grastek Ragwitek Carbaglu Rasuvo Xeljanz Acthar Sabril Hetlioz Oralair Buphenyl Ravicti 160

161 Pharmacy Management Specialty Drug List Update The Specialty Drug List and PA program are dynamic. Drugs are added to the Specialty Drug List as soon as they are approved by our P&T committee Prior Authorization, when appropriate, will be added as soon as possible. We will update the Specialty Drug List every quarter. 161

162 Pharmacy Management Multi-tiered PDL BlueChoice began converting groups to the Tiered PDL in August 2015, upon renewal. This conversion will last throughout BlueCross employer group only will also use the Tiered PDL in The main difference with the Tiered PDL is that drugs aren t tied to generic, preferred and non-preferred copayment levels. Some generic drugs and brands with no added value to more cost-effective options may be at tiers 4 through 6. Example: omeprazole-sodium bicarb (tier 4), Amrix (tier 5). 162

163 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools Ashlie Graves ICD-10 Provider Credentialing Additional Provider Reminders Closing 163

164 Web Tools

165 Web Tools Education Center The Education Center is a great place to begin your educational experience! BlueCard Medical Policies Precertification Training Manuals Webinars 165

166 Provider News and BlueNews SM for Providers Web Tools 166

167 My Insurance Manager Secure provider portal Verify eligibility and benefits View claim status Initiate prior authorization (precertification) requests Attach medical records to authorization requests View remittances Submit claims inquiries to Ask Provider Services Call Provider Services through the STATchat SM feature Web Tools 167

168 Web Tools My Insurance Manager Reminders Each user must have a unique username registered in My Insurance Manager. Due to the security of the information found within My Insurance Manager, you should never share your login information with anyone. Please contact us if you feel your username or password has been compromised. If s from My Insurance Manager are ending up in your junk folder, you may be missing out on registration confirmations for new user profiles. My Insurance Manager can provide you with eligibility information and general benefits at the service type level for BlueCard members. 168

169 Web Tools Voice Response Unit (VRU) Faxback When you get eligibility and benefits information via our VRU faxback option, we also include our latest education announcements on the cover page. 169

170 Web Tools Improving the precertification process: We re reviewing our processes and developing enhancements for you. Developing guidance to inform you what medical information we need to complete authorization requests. Adding services to the Fast-Track option in MIM. Participating in dedicated workgroups to identify and reduce inefficiencies. Designing a form to capture the minimum necessary information for specific procedures and services. Designing easier methods for you to submit documentation. 170

171 Web Tools Initial Precertification Requests Member s Name Database Number/Subscriber ID Date of Birth International Classification of Diseases (ICD) Service: CPT, HCPCS and/or Notification of Emergent Admission Provider s Name and Tax ID and the National Provider Identifier (NPI) number 171

172 Initial Precertification Requests Web Tools If any of the information is missing, we will deem the request incomplete and return it to the requestor. When this occurs, the requestor will receive this response: 172

173 Web Tools Initial Precertification Requests Incomplete or missing information can prolong the response time for your requests. Did not submit enough information to approve authorization 62 pages submitted, missing member ID and no return fax number 173

174 Web Tools Clinical Attachments within My Insurance Manager This feature is available for services that do not automatically approve. Records must be in a PDF format (other formats to come!). You can attach up to 10 documents at a time; the maximum size of a single attachment is 30MB. When you select a document, you can preview it to ensure it is exactly what you want to submit and remove it if necessary. Once you attach the document has it cannot be reviewed or deleted. 174

175 Clinical Attachments Web Tools If we receive a request and need additional clinical information from you, we will send you a request with a Request ID that is unique to that case. You can add additional documents when checking the authorization status but you must include the Request ID with future attachments. Including the Request ID ensures we can easily identify the member s case and combine clinical information with the documentation already on file. Once you attach the file, you will be able to preview the document. 175

176 Precertification Reminders: Web Tools Refer to the medical policies we use to make clinical determinations. Our medical policies are available online and include specific elements we use to evaluate eligibility of a procedure or service for benefit coverage. Avoid sending duplicate requests for precertification by phone, fax and online. This creates additional delays. All new and duplicate requests must be worked through as they are received. Verify eligibility, benefits and authorization requirements for every member encounter to avoid unnecessary denials. 176

177 Peer-to-Peer Requests BlueCross physicians will conduct peer reviews for medical necessity denials. If unable to reach the attending physician, we will leave a contact number for the physician to return the call. We will transfer requests for Peerto-Peer reviews received through our call center to the appropriate reviewer for disposition. Web Tools 177

178 Web Tools Secured Authorization Form In 2016 you will be able to submit authorizations through a secured site. You will complete the electronic form based on the service(s) you wish to authorize. You will be allowed you to enter necessary clinical data, too! More information to come. 178

179 Web Tools What s the Best Method? The chart in your packet identifies the most efficient method to get information for certain services. Service centers typically experience higher call volumes in the new year as providers verify new benefit plans. Beginning January 1/1/2016 claim status inquiries will be serviced by first going through My Insurance Manager and then Ask Provider Services if you need further assistance. 179

180 NIA Magellan Web Tools Many plans require prior authorization for advanced radiology procedures through NIA. 180

181 NIA Magellan Web Tools Non-emergency procedures that require pre-authorization are: Computed Axial Tomography (CAT) Scan Positron Emission Tomography (PET) Scan Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) To request a pre-authorization (PAs) or the status of an preauthorization: Visit or BlueCross calls to BlueChoice calls to

182 NIA Magellan Web Tools We require prior authorizations for these advanced radiology procedures: BlueCross BlueChoice CT/CTA scans CT/CTA scans CT Colonography MRI/MRA scans MRI/MRA scans Coronary CTA PET Scans PET Scans MRCP Nuclear Cardiology Studies Stress Echocardiology Visit or for a complete list of alpha prefixes for members who require PAs through NIA, NIA reference guides and frequently asked questions. 182

183 Web Tools NIA Magellan Radiation Oncology Program Became effective January 1, 2015 NIA Magellan provides the radiation oncology benefit management services. The program is designed by physicians to ensure that services within the radiation therapy treatment plan are clinically appropriate for each patient s specific condition. The program applies to radiation oncology services when performed and billed in an outpatient or office location. 183

184 Web Tools NIA Magellan Radiation Oncology Program NIA Magellan Radiation Oncology services that require PAs based on medical necessity: Low-dose-rate (LDR) Brachytherapy Three-dimensional Conformal Radiation Therapy (3D-CRT) Stereotactic Radiosurgery (SRS) Intra-Operative Radiation Therapy (IORT) High-dose-rate (HDR) Brachytherapy Intense Modulated Radiation Therapy (IMRT) Stereotactic Body Radiation Therapy (SBRT) Neutron Beam Therapy Two-dimensional (2D) Conventional Therapy Image Guided Radiation Therapy (IGRT) Proton Beam Radiation Therapy (PBT) Hyperthermia 184

185 Web Tools NIA Magellan Radiation Oncology Program NIA Radiation Oncology Matrix Use this to determine procedures managed by NIA Magellan Procedures and Allowable Billed Groups Located at and Refer to the health plan policies if the procedures are not listed in the matrix 185

186 Web Tools NIA Radiation Oncology Program Participating BlueCross and BlueChoice plans: Fully insured BlueCross Exchange plans BlueChoice Exchange plans BlueChoice commercial plans Non-Participating BlueCross and BlueChoice plans: Federal Employees Program (FEP) State Health Plan Self-funded plans Out-of-state members (BlueCard ) 186

187 Web Tools Visit for additional information about RadMD. 187

188 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Shamia Gadsden Provider Credentialing Additional Provider Reminders Closing 188

189 What You Need to Know ICD-10 The use of CPT-4, HCPCS, Revenue Codes, Mental Health DSM-5 and other codes have not been affected. What You Need to Do You may not file a claim with both ICD-9 and ICD- 10 codes. File ICD-9 codes on one claim, and the ICD-10 codes on a separate claim. If the date of service is prior to 10/1/2015 you should use ICD-9 codes if the claim is submitted after the compliance date. 189

190 What You Need to Do ICD-10 We require the applicable alphanumeric seventh character for all codes. If necessary, use a placeholder X to ensure the seventh character is in the correct data field. Providers can use My Insurance Manager to submit ICD-10 compliant claims to our plans; or resubmit a corrected claim through your clearinghouse. 190

191 Helpful Resources ICD MythsandFacts.pdf ction pdf Answers-Related-to-the-July CMS-AMA-Joint-Announcement.pdf 191

192 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Shamia Gadsden Additional Provider Reminders Closing 192

193 Provider Credentialing BlueCross, BlueChoice and BlueChoice HealthPlan Medicaid use the credentialing process to validate practitioners qualifications. BlueCross and BlueChoice credential all physicians and all mid-level providers applying for participation in any of our networks. BlueChoice HealthPlan Medicaid credentials all physicians and all mid-level providers. 193

194 Provider Credentialing The Credentialing Process We receive the application. We review the application to ensure it is complete and includes all required documentation. We send clean applications to the Credentialing Committee for review. If the Credentialing Committee approves the application, we send a notification via , and mail the executed contracts to the provider. If the Credentialing Committee does not approve the application, it is sent to the Provider Disciplinary Committee. The Provider Disciplinary Committee either approves or denies the application. We send a notification to the provider. 194

195 Provider Credentialing You can find these forms in the Forms section of our websites: South Carolina Uniform Credentialing Application Registration Form for Mid-Level and Hospital- Based Providers South Carolina Uniform Credentials Update form Request to Add or Terminate Practitioner Affiliation Change of Address Application for Satellite Location to File Claims or to Change Employer Identification Number (EIN) NPI Notification form Electronic Funds Transfer (EFT) Electronic Remittance Advice (ERA) Enrollment form EFT Terms and Conditions form 195

196 Provider Updates Provider Credentialing Updates we need to know about: Providers names Practice address Telephone number Fax number Practice office hours Practice URL (website) of Person to contact for provider updates Provider no longer accepting new patients Provider accepting new patients Physician joining or leaving your practice Age range and gender of patients accepted New or closed satellite location 196

197 Provider Updates Provider Credentialing Send all office updates to The Provider Certification department will ensure we complete your updates across all BlueCross and BlueChoice lines of business. 197

198 Provider Credentialing Electronic Solutions for Provider Updates In 2016 providers will be able to complete quarterly CMS requirements in a simple electronic format 198

199 Helpful Resources Provider Credentialing Credentialing presentation Network & Credentialing Status inquiries Fax: Electronic Funds Transfer (EFT) questions Fax: Attn: EFT Coordinator 199

200 Agenda Welcome & Introductions ACA and Exchanges Federal Employee Program (FEP) State Health Plan Upstate 1 Networks Preferred Blue (PPO) BlueChoice HealthPlan of South Carolina BlueChoice HealthPlan Medicaid BlueCard Program Ancillary Claims Avalon Healthcare Solutions Quality Initiatives Pharmacy Management Web Tools ICD-10 Provider Credentialing Additional Provider Reminders Teosha Harrison Closing 200

201 Additional Provider Reminders New Place of Service (POS) Code CMS is creating a new code POS 19 and revising the current POS code descriptor for outpatient hospital POS 22: Place of Service Code POS 19 Off-campus outpatient hospital POS 22 On-campus outpatient hospital Code Descriptor A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization A portion of a hospital s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization The effective date for these changes is January 1,

202 Additional Provider Reminders Change to Medicare Advantage (MA) Compliance CMS developed a compliance and fraud, waste and abuse (FWA) training module for use by health plans and the entities they partner (contract) with to provide services. This was done to reduce the burden on providers who were being asked to complete and attest to multiple compliance and FWA trainings from several insurers. Effective January 1, 2016, all MA plans must accept certificates of completion of this CMS Compliance and FWA training (located on the Medicare Learning Network) from network providers. Attestations will still be required from contracted network providers in 2016 as we continue to maintain our Medicare Advantage network. 202

203 Additional Provider Reminders Change to MA Compliance BlueCross MA Compliance will send a letter to network providers regarding updates to FWA training requirement for Providers can complete Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training at: (You must create a user account) MLN/MLNProducts/ProviderCompliance.html (Download training modules) (under Fraud and Compliance Awareness heading) 203

204 Additional Provider Reminders Specific Coding and Reporting Be as specific as possible in providing a diagnosis code for patients and all diagnosis codes must be documented in the patient s medical record. Submit all diagnosis codes appropriate for that patient at every visit. 10,457 records were requested this year. 7,926 could have been avoided by coding claims completely. 204

205 Additional Provider Reminders Rendering Provider NPI Reporting Requirement Effective January 1, 2016, BlueCross and BlueChoice will require you to report the rendering provider NPI on all claims. Any claim we receive without the rendering provider s information will result in a claim denial. We will accept corrected claims if your office happens to omit the rendering provider information. We recommend you submit the claims electronically using My Insurance Manager on our websites at or for faster processing. 205

206 Additional Provider Reminders National Drug Code Reporting Requirements Effective January 1, 2016, BlueCross and BlueChoice will require the reporting of the NDC, NDC unit of measure and NDC quantity for all outpatient-administered drug claims. As a reminder, when submitting NDCs on professional electronic and paper (CMS-1500) claims, you must include this related information: 11-digit NDC NDC qualifier (N4) NDC quantity NDC unit of measure (UN Unit, ML Milliliter, GR Gram, F2 International Unit) You can find additional information about the NDC requirements or the Drug Rebate Program in the Provider News section of our website at 206

207 Additional Provider Reminders New Remittance Codes Category code P5: Pending/Payer Administrative/System hold Claim status code 734: Verifying premium payment Claim status code 1: For more detailed information, see remittance advice CARC 277: The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) RARC N618: Alert: This claim will automatically be reprocessed if the enrollee pays their premiums. Note that the liability will be Other (OA instead of PR or CO). 207

208 Additional Provider Reminders Increasing Patient Reviews in 2016 Patient reviews provide insight into your patients experiences. The reviews also can attract new patients to your practice. Approximately percent of patient reviews are positive. Patients are eligible to post one review per physician encounter. Very few are using this tool! Providers can log into My Insurance Manager to respond to each patient review. 208

209 Additional Provider Reminders As part of our service efforts, we have created Palmetto Provider University. This curriculum educates new providers and their staff on our business objectives and processes Webinar Topics 2016 Benefit Update Meeting Encore Credentialing Health Insurance Marketplace (Exchanges) BlueCard and Ancillary Services Quality Initiatives Web Tools Dental Mental Health Provider Town Hall Meetings Web Precertification 209