BlueAdvantage 2010 Julie Horton, RN, MSN Principle Clinical Consultant BCBST Senior Care Division

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1 2010 Julie Horton, RN, MSN Principle Clinical Consultant BCBST Senior Care Division BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. This document has been classified as public Information.

2 Private Fee for Service (PFFS) versus PPO PFFS (No Contract) PPO* (Contracted) Platinum Diamond Gold Ruby Classic/Basic (Medical only) BlueAdvantage Plus (group plans) Sapphire BlueAdvantage Plus (group plans) *Emerald coming in

3 Private Fee for Service (PFFS) versus PPO PPO will be sold in all 95 Counties in Tennessee; PFFS will be sold by BCBST in only 5 counties Clay Cumberland Fentress Jackson Putnam 3

4 How is BlueAdvantage different from Original Medicare? Extra Services annual physical exam; lab, X-ray, EKG and preventive screenings with zero copay for in-network services Tennesseans Serving Tennesseans local claims/customer service Provider Service line Claims box see Contact Us on BCBST.com RN Case Managers and Social Workers Prior Authorization Requirements (see next slide) Risk Adjustment Medical Record Review (see later slide) 4

5 How is BlueAdvantage different from Original Medicare? Prior Authorization Requirements: Inpatient admissions: all acute care, SNF, rehabilitation and behavioral health facility admissions Speech therapy, occupational therapy and physical therapy (excludes therapy evaluations) High Tech Imaging authorizations through MedSolutions (beginning August 1, 2010*) *Note: implementation date dependent on CMS approval of communication pieces 5

6 How is BlueAdvantage different from Original Medicare? Prior Authorization Requirements (continued): Certain Part B Specialty Pharmacy Medications (see bcbst.com/providers/pharmacy.shtml) Home infusion therapy Durable medical equipment for purchase or rental if the purchase price is greater than $500 Orthotics and prosthetics if the purchase price is greater than $200 6

7 How to obtain a prior authorization Type of Service Submit via: Durable Medical Equipment (DME) Orthotic/Prosthetic (O & P) Home Infusion Therapy (HIT) Inpatient Rehabilitation Long Term Acute Care (LTAC) Skilled Nursing Facilities (SNF) Home Health Services (excluding HIT) Outpatient Therapies Inpatient Psychiatric Inpatient (Medical) Part B Specialty Pharmacy Medications 23-hour Observations Conversions Fax Only Phone or Fax Phone/e-Health Services Web Submission/Fax 7

8 How is BlueAdvantage like Original Medicare? Severity of Illness and Intensity of Service requirements Retrospective review audits Claims submission forms / Billing guidelines Documentation guidelines Required notices: - Important Message from Medicare (IMM) - Notice of Medicare Non-Coverage (NOMNC) 8

9 Risk Adjustment Program Requirements Risk Adjustment (RA) is the method CMS utilizes to compensate MA plans for the member s anticipated healthcare expenses CMS uses diagnosis codes, submitted by the plan, and demographic information to assign an RA factor and determine premium payments MA plans conduct medical record reviews to accurately submit complete information to CMS CMS and the Office of Inspector General (OIG) audit medical records to assure accuracy and integrity of RA data Medical records are selected through claims analysis and requested throughout the year 9

10 Coding and Documentation Requirements Medical records are reviewed to ensure diagnosis codes submitted can be supported through medical record documentation. Diagnoses should be reported to the highest level of specificity (250.xx) Chronic and co-existing conditions should be assessed and documented annually Per ICD-9-CM guidelines, history of means the patient no longer has the condition, accurate coding begins with complete documentation For more information, please see Risk Adjustment documentation handout at Senior Care Division resource booth. 10

11 Medicare Advantage - BlueCard BCBS Medicare Advantage PPO Network Sharing Suitcase logo File claims with local Blues plan Home plan authorization guidelines apply Host plan contracted rates apply 11

12 Medicare Advantage - BlueCard BCBS Medicare Advantage In addition to MA PPO products, a suitcase may indicate that other types of MA national or traveler coverage Examples of what you may see printed on Medicare Advantage ID cards along with the suitcase: 12

13 Blue Elite - New BCBST Medicare Supplement Effective May 1, Medicare Supplement Products BlueCross 65 will continue, but no NEW sales All NEW Med Supp sales will be BlueElite 13

14 ID Cards Identifies Product Name PPO Products BlueAdvantage Ruby BlueAdvantage Sapphire BlueAdvantage Platinum BlueAdvantage Plus (group PPO plan) Identifies Type of Plan Preferred Provider Organization (PPO) Customer Service Phone Number Claims Mailing Address Numbers that will help providers/ pharmacists file claims Co pay ments: OV (office visit) SPEC (specialist visit) IPH (inpatient hospital) ER (emergency room) V (vision) Drug Coverage Indicator: The Medicare Rx logo will only be present if the Member has elected drug coverage. 14

15 Are you focused on patient Safety for your Seniors? Falls Assessment, Education, Intervention (PQRI bonus) High Risk Medications Sedating Readmission Prevention One in five admissions will be readmitted in 30 days unless prevented. Please see handouts at Senior Care Division resource booth. 15

16 Contact Information BlueAdvantage BlueAdvantage Provider Service line: Health Management/SNF Care Coordinators: Prior Authorizations/Advanced Determinations Online WebAuth available via BlueAccess for some services Claims and UM Mailing Addresses: BCBST BCBST Claims Service Center Medical Records 1 Cameron Hill Circle, Ste Cameron Hill Circle, Ste 0037 Chattanooga, TN Chattanooga, TN BlueRx (Part D drug plan) Pharmacy Benefits Manager (PBM) Preferred Care Services, Inc: Physician Formulary Exception line: