TRICARE claims Complex claim filing is simplified

Transcription

1 HMSA s For Participating Medical Practitioners November 2008 State halts funds for Keiki Care HMSA will continue coverage through December See PAGE 5. CAHPS survey results Members provide feedback. See PAGE 4. Changes to Federal Plan 87 Changes to HMSA s Federal Plan for 2009 are noted. See PAGE 4. Understanding HMSA s Care Access Assistance Program (CAAP) Helping members who need to travel for specialty care is explained on PAGE 5. HMSA s ERx drug plan ends December 31 SRx coverage a viable option for 65C Plus members. See PAGE 2. TRICARE claims Complex claim filing is simplified on PAGE 10. Questions about information in this publication can be directed to HMSA Provider Teleservices Representatives at on Oahu or 1 (800) from the Neighbor Islands. HMSA s Online Care Visit HMSA s Online Care for Physicians at for the latest blogs, videos, and project updates. See PAGE 3. PS Field recognizes providers for 3rd quarter 2008 HMSA gives kudos to providers throughout the Islands. See PAGES 8-9. Durable cards for QUEST members to be issued Plastic cards will be Blue Shield/Blue Cross compliant. See PAGE 10. Flu shot updates HMSA community flu shot clinics and preservative-free flu shot fees. See PAGE 2. PS Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offices located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 November 2008 Provider Update - Medical Practitioners 2 No charge for flu vaccine Health plan membership card is required Driver s license or other photo ID required Must be 18 years or older No checks or credit cards accepted HMSA s ERx Drug Plan is Ending Members can enroll in HMSA s 65C Plus SRx. Reminder: Preservative-free influenza shot fees As the popularity of preservative-free influenza vaccines gains momentum, providers are reminded to discuss with members that they will have a financial obligation to pay the balance of the cost for the immunization. For more information, visit the Provider E-Library Influenza Vaccine entry where general coverage and payment information is available. HMSA s ERx prescription drug plan for 65C Plus members will end Dec. 31, ERx members may choose HMSA s Standard Prescription Drug Option, SRx, to help keep their medications affordable. except for the SRx Members can enroll in SRx between Jan. 1, For enrollment information, members can call on Oahu. On the Neighbor Islands, call toll-free 1 (800) For TTY/TDD, call (808) on Oahu. HMSA s 65C Plus is a Medicare Health Plan with a Medicare cost contract. H1251_4010_8720_0022 CMS 09/12/08 (00) GA :08 GO

3 November 2008 Provider Update - Medical Practitioners 3 HMSA s Online Care For Physicians As part of the development of HMSA s Online Care, which will connect Hawaii residents with HMSA participating physicians via the web or telephone, HMSA has started a unique online community for physicians. Physicians can preview videos for HMSA s Online Care, read HMSA s blog, ask questions, and stay informed about project milestones, leading up to the January 2009 launch of HMSA s Online Care. Physicians who register on the site will have access to even more features, such as a special product preview and tutorial. They ll get an in-depth look at what HMSA s Online Care can do and how physicians can use it. Physicians will also be able to read and post comments in the blog. This site, developed by HMSA and American Well, features all available physician information on HMSA s Online Care in one convenient location. It includes: Overview: General briefing on HMSA s Online Care. Take a Tour: Physician demonstration of HMSA s Online Care. Webside Manner: A blog hosted by HMSA executives Michael Stollar and Fred Fortin on the status of HMSA s Online Care and the future of online healthcare. Events: Video and photos from community and physician events. Online Care in the Press: Links to local and national media coverage of HMSA s Online Care, American Well, and online healthcare in general. FAQs: Frequently asked questions for physicians. HMSA s Online Care community for physicians will be updated periodically as new content is developed. Check back frequently for updates and additions. To explore HMSA s Online Care Community, visit physiciansonline.hmsa.com. Remember to join the community for maximum access and information.

4 November 2008 Provider Update - Medical Practitioners 4 HMSA CAHPS 4.0H member satisfaction survey results Results of the 2008 CAHPS member satisfaction survey indicate HMSA s PPO and HMO members are highly satisfied with their medical care. Specifically, the Shared Decision Making composite reflected a 92.6 percent result for 2007, which increased to 93.9 percent in This composite, which was introduced in 2007, is based on whether members felt that their doctor or healthcare provider discussed options with them, and asked their opinion regarding those options. Introduced in 2008 is the composite of Plan Information on Costs, which measures the member s ability to find information from the plan regarding healthcare service or equipment and prescription costs. HMSA s HPH plans CAHPS Survey Composites 2008 Results (%) 2007 Results (%) Getting Care Quickly How Well Doctors Communicate Getting Needed Care Claims Processing Customer Service Shared Decision Making Plan Information on Costs n/a 2009 Changes to Federal Plan 87 Effective January 1, 2009, the following changes will be made to HMSA s Federal Plan 87. Preventive care. Vision and hearing tests that are performed in conjunction with a covered routine physical exam are subject to the plan s physical exam benefit. Vision and hearing tests that are not performed in conjunction with a covered routine physical exam are subject to the plan s vision and hearing benefits. Vision appliances. Eyeglasses or contact lenses prescribed for a medical condition such as aphakia, cataract or keratoconus are limited to one pair of eyeglasses, replacement lenses or contact lenses (or equivalent supply of disposable contact lenses) per incident. Mental health and substance abuse. Mental health counselors have been added to the list of providers recognized to perform mental health and substance abuse services. Hypnotherapy has been added to the list of mental health and substance abuse services that are not covered. Services requiring precertification. To identify those services that require precertification under HMSA s Fed 87 plan, refer to the Provider E- library Services That Require Precertification or refer to the medical policies index for links to policies that may contain precertification requirements that apply to HMSA s Federal Plan 87.

5 November 2008 Provider Update - Medical Practitioners 5 HMSA to continue Keiki Care despite funds cut Despite the sudden cut in funding by the state to the Keiki Care Plan as of November 1, 2008, HMSA will sustain the coverage for these children through December 31, HMSA was given two weeks notice that the state would withdraw its financial support, and was not given an opportunity to discuss the decision. HMSA will meet with its community board of directors to discuss the future of the plan. Any Travel assistance through CAAP Since September 2007, HMSA s Care Access Assistance Program (CAAP) has assisted PPO members who need specialty care not available on their home islands. Providers or members can download the CAAP request form on the provider portal or hmsa. com and providers can fax it to HMSA s Medical Management department at (808) It is important that the request form be filled out with the diagnosis and procedure code, accompanied by required documentation. HMSA will review the request within 15 days and will inform the member if program guidelines are met. If so desired, HMSA will book the travel for the member. Up to $70 per one-way plane or ferry ticket is available on approved requests. Once a member has been granted CAAP approval, additional appointments with the same provider for the same condition can be arranged without completing a new request form. changes will be announced as soon as possible. The Keiki Care Plan has 2,000 children enrolled and offers a set of basic healthcare benefits. The state and HMSA paid for the monthly dues. HMSA will continue to honor its commitment to the Legislature to ensure Hawaii s uninsured rate remains one of the lowest in the nation. For more information about HMSA s Keiki Care Plan, please call on Oahu. HMSA has specific guidelines for CAAP, which is only considered for specialty care not available on a member s home island. For purposes of this program, internal medicine, family practice, pediatrics (except pediatric specialists) and rehabilitation therapy providers are not considered specialists. Services must be a benefit under the member s plan and received from HMSA participating providers. If the service requires precertification, this must be completed prior to a CAAP request. Follow-up care should be received on the home island if the specialist regularly visits. Travel assistance for a companion may be granted for minors through age 17. The companion must be a parent or legal guardian authorized to make healthcare decisions for the minor. Please provide HMSA sufficient time to make travel arrangements for companions if they are not covered under the health plan of the minor patient. The specialty provider should complete documentation at the time of service to confirm the member has received treatment. Reimbursement will be made when HMSA receives full documentation, which has the signed physician certification document and airfare receipts which include the name of the traveler, dates of travel and the amount paid. No reimbursement is made for using frequent flyer miles; change fees, regardless of the reason; and for multiple seats. Charge card receipts are not accepted. Retroactive travel requests must be received within five days of a specialist appointment date or they will not be considered for reimbursement. For more information call HMSA at on Oahu or 1 (800) for the Neighbor Islands.

6 November 2008 Provider Update - Medical Practitioners 6 Policy News CT Colonography The HMSA medical policy for indications for diagnostic computed tomographic (CT) colonography (also known as virtual colonoscopy), can be found in the Provider E-Library under Virtual Colonoscopy - Effective January 1, The New England Journal of Medicine recently published the results of the American College of Radiology Imaging Network s trial of CT colonography. These results will be evaluated by Blue Cross Blue Shield s Techonology Evaluation Committee at its December meeting. HMSA will review its policy following BCBSA s assessment and will notify providers of changes, if any. Sleep Disorder Medical Policy Replaced November 1, 2008 HMSA is rescinding its Sleep Disorders Diagnosis and Treatment medical policy which was to become effective on November 1, Medicare has sigificantly changed its coverage criteria for positive airway pressure devices for the treatment of obstructive sleep apnea. This policy will be revised to reflect these changes. Please refer to the current Polysomnography-Sleep Studies policy and the current Medicare Local Coverage Determination (LCD) (ID L27717), Polysomnography and Sleep Studies for Testing Sleep and Respiratory Disorders, which can be found in the Provider E-Library. Alpha-fetoprotein (AFP) CPT Alpha-fetoprotein (AFP) is a test used to detect types of malignancies and liver diseases, and is also used to screen pregnant women for possible fetal developmental abnormalities. Pregnant women are usually screened with the maternal quadruple screening test, which includes AFP; however, testing for AFP alone may be more appropriate under certain circumstances. Services rendered as of October 1, 2008, for claims submitted with CPT code 82105, alpha-fetoprotein serum, will be processed for payment when accompanied by specific diagnoses associated with pregnancy. A list of codes is available in the Provider E-Library under Alpha-Fetoprotein. Also included in the list are specific diagnoses for liver diseases and malignancies that would process when billed with CPT Pentacel Pentacel, a new combination vaccine that is indicated for active immunization against diphtheria, tetanus, pertussis, poliomyelitis and invasive disease due to Haemophilus influenzae type b (Hib), was recommended for use by the Advisory Committee on Immunization Practices (ACIP) on June 25, HMSA will provide coverage of Pentacel as of service date June 25, Pentacel should be coded with CPT System changes were recently implemented to allow payment of Pentacel. All services that were denied prior to the implementation of the changes will be reprocessed for payment within the next three pay cycles.

7 November 2008 Provider Update - Medical Practitioners 7 Policy News Annual review of medical policies The following policies have undergone annual review and have been updated. Photochemotherapy COX-2 Inhibitors Drug Tier for Medicare Part D Intravascular Brachytherapy Negative Pressure Wound Therapy (w/90- day notice) Omalizumab (Xolair) Lipoprotein (a) Enzyme Immunoassay (new policy) Billing and Coding Immune Globulin Therapy (changes effective February 1, 2009; a redline version is available for review) Off-Label Drug Use for Medicare Part D Please refer to the Provider E-Library to view the changes to the individual policies. Copies of the policies are available upon request. Policy archived The policy for Abatacept (Orencia) has been archived and removed from the precertification list. MAC fee change The maximum allowable charge (MAC) for the following CPT codes changed October 15, CPT New MAC Description Code 10/15/ Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years $ Pentacel $81.18 Chlamydia Screening Recommendation - Update The U.S. Preventive Services Task Force (USPSTF), along with the Centers for Disease Control and Prevention (CDC), strongly recommends clinicians routinely screen for chlamydia in all sexually active women age 25 and younger. HMSA s Care Management department recently began a physician awareness campaign based on this most recent recommendation. Chlamydia infection is the most common sexually transmitted bacterial infection in the United States. Because Hawaii ranks sixth in the nation in these infections, HMSA is committed to improving physical, emotional and financial impacts of chlamydia on its members. To request chlamydia tool kits or training for office staff, please fax an inquiry to HMSA s Care Management at (808)

8 November 2008 Provider Update - Medical Practitioners 8 PS Field recognizes Island providers For the third quarter in 2008, PS Field in September selected practitioners to be recognized for their service to HMSA and its members, and their interactions with HMSA staff. Ten PS Field servicing teams six on Oahu, two on the Big Island, one each on Maui and Kauai selected a provider or staff member of a group or facility that the team felt was deserving of recognition. Providers received a framed certificate with an orchid design, an orchid plant, and a box of cookies along with a handwritten note of appreciation. The following providers were recognized: OAHU Gloria N. Carlile, MD, a pediatrician with an office in Kailua, maintains extended office hours from 9 to 11 a.m. on weekends for the convenience of her patients. She and her office staff bring up issues for HMSA s review and attention that affect both their office and other pediatric practices. Dr. Carlile, an active participant in HMSA s Windward Physician Liaison Committee, always adds constructive suggestions. Melvin C. Wong, MD, a neurologist, raised helpful questions about a letter from HMSA to physicians about the drug dipyridamole. He provided documentation from the American Stroke Association that the drug is appropriate to use in conjunction with aspirin for stroke patients. Dr. Wong s concerns led HMSA to clarify its information regarding prescribing criteria. Shigeko Lau, MD, has provided quality care to HMSA and HMSA QUEST members since She works closely with HMSA in a very friendly and supportive way to resolve issues that arise with claims processing. Ron Winkelman, OD, recently moved to Hawaii and opened his practice in July. While undergoing credentialing as a new provider, he continued to provide vision services to HMSA members and only charged them their copayments. Although concerned about the situation, Dr. Winkelman and his office manager remained pleasant, understanding and accommodating toward HMSA members during this period. The Queen s Medical Center provides a wide range and high volume of services to patients. As a result, its Business Services unit deals with a complex mix of payers and policies. Its staff members have always interacted with HMSA in a collaborative and professional manner. They identified several situations that resulted in our initiating system changes that have improved HMSA s efficiency and processing accuracy. Michael Turner, PT, and an already established provider, worked closely with HMSA while waiting for new provider numbers to be issued for OrthoSport Hawaii. He used the time productively and eagerly accepted all available training provided by his HMSA Provider Services Field team on claims filing, physical therapy billing guidelines, TRICARE and BlueCard. He and his biller prepared claims and researched specific questions and problems. Because of this preparation, they have a strong knowledge base. Dr. Melvin Wong, shown here with two staff members, was recognized by HMSA s PS Field for the third quarter. See page 9

9 November 2008 Provider Update - Medical Practitioners 9 Kudos to providers from HMSA s PS Field reps From page 8 BIG ISLAND Dana M. Lee, MD, is positive about HMSA and what we do for providers. Besides heading a group of pediatricians in Waimea, she serves as chief of staff at North Hawaii Community Hospital and is a member of HMSA s Physician Liaison Committee. She is a very involved and caring provider. Sue Ellen Rhodes and Brenda Dunne of Medical Management Associates have kept a watchful eye over the growth of several Big Island practices in East Hawaii for many years. Medical Management Associates Brenda Dunne and Sue Ellen Rhodes with HMSA s Lynn Yoshida. As the office managers for Kilauea Rehab Inc., the Hilo Urgent Care Center and its new location Urgent Care Kea au, and Dr. Edward Gutteling s orthopedic practice, Sue Ellen and Brenda assure that these medical practices are current, from contracting to claims. MAUI Benjamin Berry, MD, has been a great asset to HMSA by being a member of Maui Physician Liaison Committee. He offers constructive suggestions and positive input about HMSA initiatives. He has a community-oriented outlook regarding patient care. Dr. Berry is known for his great bedside manner and his dedication to his patients, and his office staff is friendly and cooperative. KAUAI Office staff of Ho ola Lahui Hawaii has always exemplified positive support and patience with HMSA. They often have providers coming and going in their practice, and they are very understanding when HMSA takes a while to process their requests. Their staff is always very cooperative and professional. Signature requirement on paper CMS 1500 Effective immediately, paper CMS 1500 claims submitted to HMSA will be processed without provider signature or initials in box 31, Signature on File, so long as the correct provider ID is located in box 33b. The provider ID indicates HMSA registration.this change will bring paper claims processing in alignment with current EDI claims processing which does not require a completed Signature on File field. This change to claims information requirements is expected to reduce the amount of claim rejections and result in more efficient service for both HMSA and participating HMSA providers.

10 November 2008 Provider Update - Medical Practitioners 10 TRICARE Submitting Electronic Claims when Other Health Insurance (OHI) is Primary With more frequency, many members have coverage from more than one insurance company, which adds to the complexity of claims filing. In order to assure proper adjudication of claims containing primary payer involvement, it is strongly recommended that EDI claims include the primary payer amount allowed, paid amount, and reason if no prior payment is made on claims submitted. TRICARE follows the ASC X implementation guides for the needed elements to process. Secondary and tertiary claims can be submitted electronically through a clearinghouse, direct submission or The required information from the other health insurance (OHI) explanation of benefits (EOB) must be included in the claim submission. Electronic submission of secondary or tertiary claims via the web requires the primary payer allowed amount, paid amount, and the OHI Payment Reason code. EDI (837P or 837I) claims transactions The following outline provides the basic elements of the 837 needed for secondary and tertiary claims processing: Other Subscriber Information (SBR): The 2320 loop is required when reporting other insurance, prior or otherwise. The multiple instances of SBRs breakdown multiple payers and the claim adjudication decisions. AMT Prior Payer Paid: The 837 implementation guide requires this element if claim adjudicated by prior payer. AMT - Allowed Amount: Allowed amounts can be provided at the AMT. However, if the AMT cannot be reported, the Claim Level Adjustments (CAS) segment is necessary to adjudicate. OI - Other Insurance Coverage Information: Required if 2320 loop is present. To submit line level OHI information, refer to the WPS 837 Companion Guide which can be found in the Your EDI Connection area of Note: TriWest pays claims with OHI line-by-line. That means that if the other carrier pays on some lines and not others, TriWest will consider each service on its own merit. The TRICARE EOBs show the beneficiary responsibility. If it is 0, the beneficiary cannot be billed and has no out-ofpocket expenses. QUEST members to soon have plastic membership cards Soon, HMSA will be issuing plastic HMSA QUEST membership cards to replace the current cardstock QUEST cards and to comply with new Blue Cross Blue Shield membership card requirements. The information presented on the new QUEST membership cards do not contain family member information. As a result, QUEST members will now receive their own individual membership card with only their individual information on the card.