Blue Cross and Blue T Shield of Kansas Hospital Quadrant Meetings

Transcription

1 Blue Cross and Blue T Shield of Kansas Hospital Quadrant Meetings August 2013 An independent licensee of the Blue Cross and Blue Shield Association 1

2 Today's Presenters: Connie Winkley, o Education Coordinator, Institutional Relations, BCBSKS Denny Hartman, CPC o Provider Representative for Southern Kansas, Institutional Relations, BCBSKS Cindy Garrison, CPC o Provider Representative for Northern Kansas, Institutional Relations, BCBSKS BCBSKS Marketing Representative Marie Burdiek o Account Representative, Electronic Data Interchange (EDI), BCBSKS 2

3 Today's Meeting Agenda: New BCBSKS Institutional Provider (IR) Staff Availity Web Portal ICD-10 Updates Electronic Inpatient Precertification 2014 Policies and Procedures Hospital Abstracts 2014 Quality- Based Reimbursement Program (QBRP) Miscellaneous Billing Guidelines Non-contracting Provider Billing Procedures HealthCare Reform (HCR) Products Top 10 Denials New Services/New Procedures Electronic Data Interchange (EDI) Q & A Evaluations 3

4 New BCBSKS Institutional Relations Department Staff IR Organizational Chart Fred Palenske Senior VP Provider & Government Affairs Angie Strecker Director Institutional Relations Dona Hewes Administrative Coordinator Teresa Van Becelaere Manager Institutional Relations Cindy Garrison Provider Representative Hospitals in Northern KS Denny Hartman Provider Representative Hospitals in Southern KS Melanie Moriarty Administrative Assistant (Topeka Office) Cheryl Carner Administative Assistant (Wichita Office) Connie Winkley Education Coordinator Janne Adams-Denton Contract & Specialty Provider Consultant Katie Dennison Claims Research Analyst Brent Matile Quality Reimbursement Analyst 4

5 Introducing the new BCBSKS Institutional Relations Department Staff Janne Adams-Denton Contract & Specialty Provider Consultant Katie Dennison Claims Research Analyst Brent Matile Quality Reimbursement Analyst

6 Availity Web Portal Blue Cross and Blue Shield of Kansas (BCBSKS) began their business relationship with the Availity Health Information Network in In March 2012, BCBSKS moved their member eligibility and verification, as well as claim status information to the Availity web portal. These transactions for BCBSKS members are available with no cost to the provider. Availity offers a multi-payer portal at that gives physicians, hospitals and other health care providers secure access to multiple payers information through a single sign-on. Providers who require other online services, such as precertification, will be redirected back to the secure section of the BCBSKS Website without having to sign-on again. Several publications regarding Availity have been published on the BCBSKS Website over the past 18 months for the provider's information and transition to Availity, including the following newsletters: BCBSKS now on Availity Portal Availity Web Portal It is important for the providers to know that, beginning August 19, 2013, Availity will become the exclusive portal for online access to all secure information on Blue Cross and Blue Shield members in Kansas. This means BCBSKS will require all of our providers to use the Availity Web Portal for online claims status inquiries, and eligibility and benefits verification. Providers who require other online services, such as precertification and viewing a remittance advice will be re-directed to the secure section of without having to use a separate login. Providers can also continue to use real time transactions through their clearinghouse or vendor. BCBSKS encourages our contracting providers to act prior to August 19th so that you will continue to have online access to this secure information on Blue Cross and Blue Shield members in Kansas. You should allow three to five business days to complete the registration process with Availity. Registering with the Availity Web Portal is FREE and easy: Go to Click Register Now. Complete the online registration wizard. Provide your organization s name, address and federal tax ID number. Designate a Primary Controlling Authority (PCA), a person who signs the Availity access agreement for your organization. Designate a Primary Access Administrator (PAA), a person responsible for assigning the Availity functions/permissions to other users at your organization. This person is commonly the office or department manager. You will receive an from Availity with a temporary password and next steps

7 ESTABLISHING SECURE ACCESS (PROVIDER LOG-IN) Effective August 19, 2013, all contracting BCBSKS providers are required to access secure BCBSKS member's information through the Availity Health Information Network portal ( Providers can get access to both the Availity Web Portal and BlueAccess (BCBSKS' secure web portal) to view secure BCBSKS member's information with a single-sign. Once providers are granted access to Availity from their Primary Access Administrator (PAA) the provider can then link back to BlueAccess from the Availity web portal by following the steps beginning on the next page. Each hospital that contracts with BCBSKS has been assigned a PAA within the facility who will be responsible for giving access to their hospital staff to the Availity web portal. Anyone who requires access will need to contact the facility's assigned PAA or Availity to get registered for the Availity web portal. If you do not know your facility's PAA, contact Availity at AVAILITY. Log on to Availity at and become familiar with the information available on the Availity Home Page. Click here to view your PAA Your name as it is registered with Availity For questions or problems with the Availity web portal, contact Availity at AVAILITY or by Your Name Check out the online demos and Free Training options! Rolling screen with additional resources and information NOTE: Effective 8/19/13, Providers can only access BCBSKS member's Eligibility and Benefits and Claims Status information on the Availity portal; this information will no be longer available on the BCBSKS secure website (BlueAccess). Some information and access continues to remain on BlueAccess after 8/19/13, (i.e. Precertification and Remittance Advices), however providers must go thorough the Availity web portal to access that information. View any current Availity announcements on this Availity (Home) page

8 Once registered with Availity and logged on to the Availity portal, providers will be able to get back to the BCBSKS secure website (BlueAccess) to access secure member information by following the Steps 1-5 below: Your Name Step 1: Click on Payer Resources on the Availity Home Page Your Name Step 2: Click on BCBSKS 8

9 Your Name Step 3: Click on a Provider Tool Option (Secure Access to Member Information on BlueAccess) Your Facility Name Step 4: Select your facility name. Use the drop down, if necessary. Step 5: Click Submit 9

10 After following Steps 1 5 on the Availity web portal, providers are then directed back to the BCBSKS secure website (BlueAccess) to view the secure services on BlueAccess. The next screen providers will see after completing steps 1 5 will be the BlueAccess screen (as shown below). Providers can now access secure BCBSKS member's information (i.e. Precertification or Remittance Advice), as well as public information (i.e. Publications and Medical Policies). BlueAccess Your Facility Name should appear here Your Facility Your Name Your Name should appear here Click on an option under Services for access to secure BCBSKS member information. CONTACTING AVAILITY: Availity Website Availity Client Services AVAILITY ( ) 7:00 am 6:00 pm CST By - support@availity.com Jan Popa, R.N. Market Specialist - Kansas Availity, LLC cell Janice.Popa@availity.com

11 ICD-10 UPDATES BCBSKS launches ICD-10 Provider Web Page May 2013 Blue Cross and Blue Shield of Kansas has launched a new web page on the BCBSKS Website specifically for providing ICD-10 information. The information on the ICD-10 web page is designed to serve as a resource to help our providers prepare for the U.S. health care industry's change from ICD-9 to ICD-10 for medical diagnosis and inpatient procedure coding. Click on the link to view the new web page or copy and paste the URL into your web browser. BCBSKS ICD-10 Web Page This web page will be updated with newsletters, resources and FAQs and will include a link for providers to submit their ICD-10 questions by an form and have an answer appear in the FAQs under the ICD-10 section. Make sure you visit the site regularly to assist you with the transition to ICD-10 prior to the implementation date of October 1, Blue Cross and Blue Shield of Kansas encourage you to check out all of the information contained within this section as well as the helpful web links. Some of the information provided here has been developed by the Centers for Medicare and Medicaid Services (CMS), and may assist you in the transition to ICD-10. For additional details, see the cms.gov Website

12 12

13 ICD-10 UPDATES BCBSKS Readiness BCBSKS has completed an impact assessment/gap analysis. We are prepared to meet the Oct. 1, 2014 deadline. BCBSKS has completed a review of our medical policies and our system changes. We are currently working on upgrading systems identified in the review phases. We continue to work on mapping the ICD-9 codes imbedded in our claims system to ICD-10. End-to-End Testing End-to-End testing will begin April 2014 and will continue through September End to-end testing will involve a facility submitting an ICD-10 claim to BCBSKS and ensuring the claim passes as a clean claim. If the claim is clean, then BCBSKS will take the claim all the way through our system and produce a remittance advice for the provider. BCBSKS will track every one of these claims to ensure they make it through and without any issues. Additional BCBSKS ICD-10 Testing Information: BCBSKS has identified some claims scenarios that we will want to test with providers and likewise, providers should bring specific claim examples to BCBSKS that they want to test during the End-to-End testing period. This will be more of a claim by claim test versus a batch file. More information on the specific process will be communicated at a later date. Providers are encouraged to work with your BCBSKS Provider Representative if interested in ICD-10 testing

14 ELECTRONIC INPATIENT PRECERTIFICATION Contracting providers shall provide notice for all BCBSKS members admitted for inpatient care. This notification will be required at one of the following: Prior to the admission The day of admission The first working day following a weekend or holiday BCBSKS upgraded their precertification system with the 2013 InterQual clinical criteria and software in July Updates on the implementation date and additional instruction and materials on the use of the 2013 InterQual version was sent to our providers in the following documents on our website: Changes due to InterQual 2013 upgrade With the release of InterQual 2013, the format and process flow of submitting clinical information remains the same. Likewise, the condition specific subsets remain the same, although additional subsets have been added. However, the most notable changes to InterQual with this upgrade include: The process flow for the procedure criteria subsets will change significantly with the change to a Question and Answer (Q&A) type format. You will be prompted to answer questions by selecting the appropriate response for the patient. You will have the option of seeing a list of recommended procedures. This is a list of the surgical procedures recommended based on your responses (see the attached Precertification Manual for further detail). The Pediatric and Adult procedures have been combined for the procedures criteria. Providers will choose the CP: Procedures for the InterQual Product with this upgrade. Some points to remember when loading electronic precerts: BCBSKS reviews all inpatient hospitalizations as separate and distinct episodes of care. Therefore, each admission is evaluated to determine the appropriateness of level of care, services provided, and length of stay. This may differ from the review process as outlined in the 2012 InterQual version. In order to prevent duplicate precert requests, providers are encouraged to search "Precertifications in process" prior to loading one into the system. Mark the appropriate criteria boxes in InterQual

15 Updated Precertification Information on the BCBSKS Precertification Web Page includes: Precertification Manual (updated 7/2013) Closing Precerts for Discharged Patients - 7/2013 Medical Review - Precertification / Prior Authorization Electronic Inpatient Precertification Helpful Hints Precertification FAQs Precertification Contact Information Availity Website Access and General Inpatient Precertification and InterQual Information Connie Winkley Education Coordinator Coding for Inpatient Precertification Denny Hartman BCBSKS Provider Rep for Southern KS Hospitals Coding for Inpatient Precertification Cindy Garrison BCBSKS Provider Rep for Northern KS Hospitals Clinical Questions about InterQual and Medical Criteria BCBSKS Precertification Department Problems with BCBSKS Secure Access (BlueAccess) BCBSKS Help Desk Problems with the Availity Web Portal Availity Client Services AVAILITY

16 2014 Changes coming to BlueCard Electronic Precertification Electronic pre-service review including notification, precertification, pre-authorization and prior approval is currently available to many local providers. Out-of-area providers who want to conduct pre-service review generally have to call Home Plans directly for authorization or use the BLUE number, an inefficient process for providers and costly for Plans. This will change with the implementation of Electronic Provider Access (EPA) on January 1, Plans will implement modifications to local provider portals to enable providers to be routed from Host to Home for pre-service review. The Blue Cross and Blue Shield Association will facilitate the routing by providing a web service that will identify the appropriate Home Plan by alpha prefix. Effective January 1, 2014 there will be approximately 33 Blue Plans that will have electronic pre-service review for inpatient services available to out-of-area providers. Note the name change to Pre-service review which includes precertification, pre-authorization and prior approval. The EPA implementation will enable out-of-area providers to conduct pre-service review electronically in the Home Plan portal. Providers will use local Plan portals to be routed to Home Plan portals for access to pre-service review capabilities available to local providers. This includes electronic pre-service review capabilities offered through Home Plan vendors. Further provider education will be coming soon regarding the implementation of this change to BlueCard Precertification

17 2014 Policies & Procedures Update Replaced the reference to each individual product with all benefit programs, indemnity plans and self-insured plans Clarified amounts billable to the patient Reworded for ICD-10 claims submission requirements o Coding to highest specificity o NEC and NOC codes not accepted when a specific code is available o Consider modifiers or add-on codes for additional reimbursement Request for information; Medical Records o Must provide at no charge o Provide to BCBSKS or an entity acting on behalf of BCBSKS Request for information; Quality of Care o Concerns referred to Nurse Coordinator for care coordination, quality improvement and accreditation o Failure to respond constitutes further actions Amendments to signed Provider Agreement o Providers permitted to disclose PHI for purposes of treatment, payment or operation o Examples of reasons PHI would be needed: 1. Quality assurance and quality improvement activities 2. Accreditation activities 3. Case management, care coordination and related functions 4. Credentialing provider or health plan performance evaluation 5. Training 6. Certification 7. Licensing Amendments to signed Provider Agreement o Insolvency, Receivership and Liquidation Providers can only look to a member for deductibles, coinsurances, copayment and non-covered amounts in the event of formal insolvency, receivership or liquidation proceedings involving BCBSKS

18 KANSAS HEALTH DATA SYSTEMS & HOSPITAL ABSTRACTS Kansas Health Data Systems (KHDS) is a unique department within Institutional Relations. KHDS is responsible for the processing of Medical Record abstracts and providing facility education to efficiently complete abstracts for all contracting hospitals in Kansas who submit inpatient claims. An abstract is a separate document, which must be present for BCBSKS inpatient claims to process completely. KHDS is a vital area of BCBSKS in which DRG validations and reimbursement audits have been made possible by efficiently transferring data through internally-developed systems. KHDS Notes: Hospital abstracts are designed to confirm the accuracy of the MS-DRG Paid claims and abstracts are required to match Audits done and adjustments are made when needed Types of adjustments made by KHDS: Have abstract and no claim MS-DRG s don t match Incorrect diagnosis or procedure code Incomplete Present on Admission (POA) indicator Incorrect admit or discharge dates Abstracts are a contractual obligation Must be transmitted monthly (45 days from the end of each month) Each hospital will build their file from internal vendor or key in using My Ability or IVANS Option to send in BCBSKS data only or data for all payers KHDS facilitates sending inpatient data to Kansas Hospital Association for those facilities who submit all payer abstracts KHDS Contacts: Deanna Karle, Manager, KHDS, Todd Colglazier, Health Information Systems Rep, KHDS - KHDS@BCBSKS.com

19 2014 Quality Based Reimbursement Program Mailed end of July First reporting due November 15, 2013 o Reminder will be sent end of October, 2013 o sent within 5 days of BCBSKS receiving attestation o Results sent December 1, 2013 o Effective date, January 1, 2014 Second reporting due May 15, 2014 o Reminder sent end of April o sent within 5 days of BCBSKS receiving attestation o Results sent on June 1, 2014 o Effective date of July 1,

20 GENERAL CLAIMS ISSUES Multiple encounters (2 ER visits) same day = 2 claims o Make notation in Box 80 (remarks field if multiple visits) Multiple services same day: o 2 chest x-rays = 1 line item with units of 2 and notation in Box 80 o 2 inhalation therapy treatments = 1 line item with units of 2 and notation in Box 80 and times of day patient came in Observation (OBS) o Report on one line and number of hours in units field o Reimbursed at 1 semi-private room rate or charges; whichever is less o Important to keep your Room Rates up to date! o You must go by Provider s orders o If Provider changes orders from in-patient to OBS, then you can charge OBS as long as the orders are changed before discharge

21 Non-Contracting Provider Billing Procedures There are times when a facility does not have the necessary equipment or staff to perform a service in its entirety. When this occurs the facility will either refer or outsource the service to another provider. If that referred/outsource provider is non-contracting, then the facility is required to file for all services rendered and the member is to be held harmless for the use of a non-contracting provider. Transfers or Referrals When necessary, the Contracting Provider agrees to refer and/or transfer BCBSKS members to BCBSKS contracting providers. When a contracting provider uses a non-contracting provider (either in or out of state) to perform a portion of service (e.g., professional component, technical component or other technology utilized in the performance of a service), the Contracting Provider must bill BCBSKS for all services. If the non-contracting provider bills the member or BCBSKS, the Contracting Provider will be required to hold the member harmless. The contracting facility would make payment arrangements with the non-contracting provider to be paid by the facility. The non-contracting provider should not bill the member or BCBSKS

22 Top 10 Denials Last year we showed you a list of the Top 10 Denials statewide. In that report duplicate claim denials was #1. This year Corrected Claim is #1. Comparing last years report to this year there have been some improvements and some setbacks. Claim Adjustment Reason Code Remit Remark Code Reason 18 None Duplicate claim/service 96 N130 Non-covered service(s)/charge(s) 16 N202 M118 M58 Claim/service lacks information which is needed for adjudication. Additional information/explanation will be sent separately. 97 MA67 N185 M49 M86 A corrected claim or a claim that needs to be combined with another claim has been received and will adjudicated or benefit for service is included in the payment/allowance for another service/procedure 27 N30 Service(s)/charge(s) incurred after contract terminated 96 N216 Non-covered charge(s) 115 None This claim or line has been cancelled N30 The patient was not eligible for benefits at the time of service B11 None Claim has been forwarded to the local Plan for processing 23 M43 The Medicare payment is greater than or equal to the maximum allowable payment under the patient's contract

23 13,270, THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS AND/OR ADJUSTMENTS. 41,810, CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION. 7,422, THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE PAYMENT/ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE THAT HAS ALREADY BEEN ADJUDICATED. 5,663, MV 16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION. CONFIDENTIAL/PROPRIETARY INFORMATION TOT CHG CLM LI CT DNL ARC DS 147,332, FR 97 CORRECTED CLAIM 73,099, DUPLICATE CLAIM/SERVICE. 110,477, LM 131 CLAIM SPECIFIC NEGOTIATED DISCOUNT. (PLAN 65 SELECT) 2,550, M0 96 NON-COVERED CHARGE(S). (PLAN 65) 10,284, EXPENSES INCURRED AFTER COVERAGE TERMINATED. 7,154, NON-COVERED CHARGE(S). TOTAL CLM LI CT DOS 01/01/13-07/01/13

24 New Services / New Procedures As healthcare evolves, facilities look to see if there are new opportunities for them to provide services to their community. As the facilities does this, keep in mind to notify BCBSKS of any new or expanded services. As noted in the facility contract, we desire to know so that we may inform you if member contracts will cover the service(s). The same holds true for new technology or equipment the facility might add. New or Expanded Services New Techniques And Technology The Contracting Provider agrees to notify BCBSKS of the addition of new services or the expansion of existing services. The purpose of this notification is to allow BCBSKS to determine if the new or expanded service is covered under the terms of the various member contracts. Maximum allowable payment (MAP) for new techniques and technology will be based, when possible, on existing procedures of comparable value and result. Additional allowances for new techniques or technologies will be considered if there is significant improvement in safety or efficacy of patient care