[Dr. Gollhofer. believes provider. relationships are. getting better. thanks to plans. like Premera. Blue Cross.] Contents

Transcription

1 [Dr. Gollhofer beliees proider relationships are getting better thanks to plans like Premera Blue Cross.] Contents Orthopedic Network Expands page 2 New National Accounts page 3 Enhanced Maternity Coerage page 4 BlueCard Update page 4 New Proider Relations Team page 5 Care Management Helps page 6 News You Can Use page 6 Dr. Gollhofer Visits Enhancing Relations between Physicians and Plans In an effort to improe Premera Blue Cross relationships with the doctors who sere our members, Premera Blue Cross is meeting with physicians and professional organizations. For example, we recently hosted John Gollhofer, MD, former President of the Washington State Medical Association. As a leading representatie of the physician community, Dr. Gollhofer proided aluable information on how physicians perceie our company and the industry, plus how we can most productiely work together to sere our members. Dr. Gollhofer toured our Mountlake Terrace campus and shared his perspectie with our medical directors and senior management. He saw our call center where we field 3 million patient calls a year. He obsered our operations staff who process more than 12 million proider claims a year. He witnessed first-hand our efforts to make it easier for physicians to do business with us. The State of the Industry Dr. Gollfhofer ended his isit with these obserations to Premera Blue Cross ice presidents and senior management: The world is all about relationships, and certainly medicine is all about relationships especially one-to-one proider-to-patient relationships. We hae to come together as health plans and physicians, seeing each other s perspecties to gain a sense of where we re all coming from. In the past, there hae been poor relationships between proiders and plans. There s a belief in the trenches that plans are often an impediment to giing patients care. Dr. Gollhofer beliees relationships are getting better thanks to plans like Premera Blue Cross. He noted that continued on page 2 Network News Expands Audience With this issue, we begin sending Network News to all types of proiders, not just MDs, DOs and ARNPs. We beliee it is important to keep all our physicians and proiders informed about changes, updates, new programs or regulatory information that may pertain to their practices. Our expanded audience includes: chiropractors, home health and home/durable medical equipment proiders, facilities, labs, physical therapists, mental health professionals and optometrists. We realize that eerything in the newsletter will not pertain to eery physician or proider type. Pick and choose what is applicable and enjoy reading whateer else interests you. FEBUARY 2001 NETWORK NEWS

2 For Physicians and Proiders Enhancing Proider Relations continued from page 1 Premera is reaching out to make things better and asking, What do physicians want? What we must all understand is that we hae different areas of expertise and focus. Physicians recognize that being a health plan isn t easy. It s the golden goose syndrome, Gollhofer adds. Physician practices that take on financial risk hae fallen on hard times, and physicians are making huge concessions to keep their practices going. Many can t surie. Without health plans, they re in chaos. Where would doctors be if plans shut their doors? Physicians depend on the payment system that plans offer. What Are the Options? Dr. Gollhofer says that the Washington State Medical Association has looked at other ways to delier and finance health care, but there s no better way than the current system. We need to work together to improe things, he said. We need to talk to each other, not complain. We need to eliminate non-alue-added steps. We need to stop arguing and start working together toward positie relationships. He obsered that physicians take all the clinical risk, while plans take all the financial risk. He thinks we need to align these issues and work together to minimize risk for both sides. If we can learn to help each other and share our resources, we will moe ahead. Dr. Gollhofer beliees the following options are possible solutions if we work together: Deise a system where proiders hae time to care for patients and are paid fairly. Restore physicians ability to practice medicine and do it right. Sole administratie burdens. Share best practices and reduce ariations in treatment. Finally, he beliees that if we can build collaboratie relationships among physicians, proiders and plans, then balance this with consumer expectations, we can take a whole new approach to giing our members access to the quality care they need and haing a strong network to proide that access. Credentialing Team Does It Again. This team knows the meaning of teamwork and Manager Frank Barrows will be the first to tell you so. They hae been recognized not once, but twice, by the Blue Cross Blue Shield Association as a best practice team and receied two NCQA accreditations (1996 and 1999). Team members pictured l to r are: (back row) Janet Hawes, Gail Armstrong, Noreen Bissett, Claudia Olson, Bren Schwab; (middle row) Marcy Roche and Marcia Cannon; (seated) Cindy Bergley, Ann Fuda and Manager Frank Barrows. Not pictured: Anita Hegwald and Inez Chubb (Spokane). Spokane Area Expands Orthopedic Network We are pleased to announce that all orthopedic surgeons in the Spokane area are participating again in our physician and proider network as of Jan. 1, Returning clinics and physicians include: Orthopaedic Specialty Clinic of Spokane, Inland Orthopaedics of Spokane, Spokane Orthopaedic & Fracture Clinic; Northwest Orthopaedic & Fracture Clinic, Associated Orthopaedic Specialists and Alex R. Verhoogen, MD. The return demonstrates the ability of Premera Blue Cross and the physicians to work out our differences, improe how we work together and put patient and member needs first. All Premera Blue Cross health plans are affected including: MSC/Premera Blue Cross Traditional and Preferred (PPO) Premera Blue Cross Participating and Preferred (PPA) Premera Blue Cross Blue Choices Premera Blue Cross Indiidual Managed Care (IMC) Premera HealthPlus Note: MSC Care, PrimeCare, and Classic Care plans hae had access to each orthopedic surgeon all along. continued on page 3 NETWORK NEWS 2

3 For Physicians and Proiders Spokane Orthopedists continued from page 2 Primary care physicians and proiders may now refer patients to any of these orthopedic surgeons in Spokane. Serices receied from these physicians will be coered at the highest benefit leel as outlined in each member s contract. If you hae any questions, please contact your Proider Network Executie or Proider Network Associate. Moing Up Daid Johnson, MD, has just been promoted to Regional Medical Director for Eastern Washington. Dr. Johnson has been in the Spokane area with MSC/ Premera Blue Cross since Prior to that, he was a Daid Johnson, MD practicing physican at Group Health Northwest. He attended Thomas Jefferson Medical College in Philadelphia and receied his training in Family Practice in Lancaster, PA. He is currently attending Gonzaga Uniersity to earn an MBA. Preentie Health Guidelines Primary-care proiders and obstetric/gynecological proiders recently receied a copy of Premera Blue Cross updated Preentie Health Guidelines and Healthy Kids Supplement. In addition to the guidelines, we hae updated existing medical record documentation tools. These are aailable to proiders upon request. Documentation tools (aailable at no cost) include: Pediatric Immunization Flow Sheet Adult Health Maintenance Flow Sheet Pediatric Health Maintenance Flow Sheet Healthy Kid/EPSDT Flow sheets for: infancy early childhood late childhood and adolescence. Early Periodic Screening and Deelopmental Testing (EPSDT) is known as Healthy Kids in Washington state. This set of preentie health serices outlined by the Health Care Financial Administration as part of the Balanced Budget Act of 1997 ensures underpriileged children receie recommended health screenings. Premera Blue Cross members will receie a Mapping Your Way to Wellness booklet ersion of the Preentie Health Guidelines in the March issue of HouseCall. It lists the recommended preentie health serices by age and gender. You can find the guidelines and documentation tools on our Web site at You can also contact us at , ext. 5995, to request additional copies of the guidelines and/or a supply of documentation tools for your office. New National Accounts Kroger Traditional and PPO The Kroger Co. (through Anthem Blue Cross in Ohio) has awarded Premera Blue Cross its national health-care coerage for Traditional and PPO plans as of Jan. 1, Kroger members hae an alpha prefix on the member s ID card KRO for PPO members and KRG for Traditional members. NASCO will manage Kroger claims, so submit claims to: Premera Blue Cross NASCO P.O. Box 3048 Spokane, WA Alcoa PPO Alcoa Primary Metals and Intalco Works in Ferndale hae Blue Cross coerage through the BlueCard PPO program administered by Premera Blue Cross. Alcoa members are coered as of Jan. 1, 2001, and can be recognized by the prefix APM on their ID cards. BlueCard Expansion Through our affiliation with the Blue Cross Blue Shield Association, we continue to increase our national account membership with the BlueCard program. We hae been selected to administer PPO benefits in Washington and Alaska for the following national accounts: United Parcel Serice, Pepsico, Waste Management, Xerox and Morgan Stanley Dean Witter. These accounts represent more than 8,000 members in Washington and Alaska, in addition to the more than 100,000 national members we currently sere through this program. To erify benefits for these members, please call toll free to (BLUE). Claims for members in all national accounts can be filed electronically. Be sure to ask members for their current ID card and always include the three-letter alpha prefix preceding the member s ID number. If you hae questions or require additional information, please contact Proider Relations at NETWORK NEWS 3

4 For Proiders and Practice Management Get Ready for a Whole New Way of Doing Business We will introduce a new plan design in early 2002 offering increased customer choice, ebusiness connectiity and administratie simplicity. The modular design will gie customers the flexibility to select plan features and cost-sharing options that meet their health-care needs and budget. We are also simplifying and streamlining our business processes to make it easier for you and your patients to work with us. The new plan design and simplified business practices will be supported by a state-of-the-art claims processing system. We are confident these changes will enable us to work together more efficiently, which means better serice to you and your patients. Enhanced Maternity Coerage for Indiidual Plans Premera Blue Cross reentry into the indiidual insurance market brings with it a change in how we process indiidual plan maternity benefits and claims. Prior to re-entry, most indiidual plans either did not coer maternity or proided a ery limited benefit. Now, with the exception of catastrophic health-care plans, all indiidual plans will coer maternity the same as any other serice. Consistent with other serices, maternity care on indiidual plans is subject to a nine-month waiting period for pre-existing conditions. Howeer, benefits for prenatal care (serices rendered prior to the commencement of labor or deliery) are exempt from the waiting period, and benefits for such care will be aailable as soon as the patient s coerage takes effect. This waiting period can affect claims processing if you bill a global maternity fee for a patient who is subject to a pre-existing condition waiting period. In this case, the claim may be returned to you with instructions to rebill with the prenatal care serice dates identified. If you hae questions regarding a patient s maternity coerage, contact the Customer Serice number on the back of the patient s ID card. Premera HealthPlus Merges into Premera Blue Cross Premera HealthPlus merged into its parent company, Premera Blue Cross, on Dec. 31, The merger reflects a legal change in corporate form only and in no way changes patient benefits or the physician and proider network. Claims and customer serice are handled as usual. BlueCard Update When you see Blue Cross or Blue Shield HMO patients from out of the area, we want you to handle claims for these members the same way you do for Premera Blue Cross members and Blue Cross Blue Shield Traditional, PPO and POS patients from other Blue plans - submit them through the BlueCard program. You can identify all Blue Cross Blue Shield members by the three-character alpha prefix preceding the member s number on the front of their ID card. You may also see the empty suitcase identifier below, which indicates that the claim should be filed through the BlueCard program. Handling Claims Here s how to handle claims for HMO members affiliated with other Blue Cross Blue Shield plans: With the member s ID card in hand, call BlueCard eligibility at (BLUE). When asked, tell the operator the member s threecharacter alpha prefix. When the member receies care, do not ask for full payment up front other than out-of-pocket expenses (deductible, copayment, coinsurance and serices that are not coered). Submit the member s claim with the member s complete identification number, including the alpha prefix, to Premera Blue Cross. We will send you an Explanation of Payment or payment adice. If you hae any further questions about Blue Cross Blue Shield HMO members affiliated with other Blue plans and/or the BlueCard program, call BLUE (2583). NETWORK NEWS 4

5 For Proiders and Practice Management New BlueCard Identifier Premera Blue Cross has just started using a new BlueCard program identifier on non- BlueCard PPO patients identification cards. The new empty suitcase identifier (as aboe) proides easy recognition of these members and will be on all cards for Blue Cross Blue Shield members in non-bluecard PPO plans. BlueCard PPO members will still hae the suitcase with PPO inside it. There is no change in the way you submit claims for BlueCard patients. Member Access to Emergency Serices We hae an Emergency Serices Policy to ensure that members hae appropriate access to emergency serices. Our policy complies with both National Committee for Quality Assurance (NCQA) standards and Washington state law. Emergency serices are coered under the following state law: A health carrier shall coer emergency serices necessary to screen and stabilize a coered person if a prudent layperson acting reasonably would hae belieed that an emergency medical condition existed. In addition, a health carrier shall not require prior authorization of such serices proided prior to the point of stabilization if a prudent layperson acting reasonably would hae belieed that an emergency medical condition existed. New Proider Relations Team Ready to Sere You There s a new team in Health Care Deliery Systems that has become call central for physician and proider network questions and issues. We heard what our physicians and proiders were saying and wanted to gie them better turnaround time when they call in, says Nancy Stewart, Eastern Washington Physician and Proider Relations Manager. Our team of seen Proider Network WE CARE. The Proider Relations team is eager to lie up to its alue statement: We care. Shown here, Acting Manager Brian Hake with Proider Network Representaties (l to r) Sandi Larsen, Cheryl Watson, Tricia Green and Alicia Cox (seated). Representaties [PNRs] (three in Spokane and four in Seattle) will take calls from 8 a.m. to 5 p.m. PST (see phone numbers at end). Most times callers will reach one of our PNRs directly, but on occasion, our oic will pick up the message, and we will return the call within 24 hours. The new team was formed after surey feedback from physicians and proiders indicated we needed better response time to phone calls. This team will quickly respond to any questions you may hae, including: panel status address changes tax identification number updates directory requests or updates physician or proider clinic additions contract status. We alue our physicians and proiders because they are a ital component of successfully meeting our members health-care needs, says Brian Hake, Acting Western Washington Physician and Proider Relations Manager. So sering them well seres our members well. Our goal is to either resole the issue at the time of the call or research it and keep physicians and proiders in the loop until it is resoled. The numbers for the new team are: ( Western Washington and Yakima) or ( Eastern Washington). NETWORK NEWS 5

6 For Proiders and Practice Management Your Patients Are Our Members Care Management Helps Struggling Family In a time when health-care plans are frequently thought of as gatekeepers, we re committed to being gate openers. A recent case demonstrates how we worked with an agency to get a whole family help. It began when one of our care managers authorized an initial home-health ealuation with Proidence Sound Home Care for a family struggling with caring for a premature baby. Proidence informed the case manager that the mother was haing what appeared to be post-partum depression. She was not eating or drinking herself, nor feeding the baby, so Dad was doing his best to take care of the infant. The care manager immediately referred the case to a Premera Blue Cross case manager who contacted multiple physicians, home-health staff, superisors and the care manager to coordinate benefits and get the mother the necessary psychiatric help. The ery impressed home-health representatie told our care manager how great she thinks Premera Blue Cross is. She also told our care manager that in this era of bad press for health plans, she is proud to share this wonderful Premera Blue Cross interention and its positie impact on this patient s care. If you hae a story to share of how we e helped you or your patients, we d loe to hear from you. Just contact Editor Linda Forrester (see credit box on last page). News You Can Use Get the Most Out of Our Enhanced Referrals Process Remember, you can use our new central numbers for phoning and faxing PCP referral requests to any of our managed-care plans. Referrals apply to all Premera Blue Cross, MSC incorporated as Premera Blue Cross and Premera HealthPlus managed-care products for physician and proider offices. Indemnity or preferred plans do not require referrals. Keep the following points in mind to speed your request: The centralized numbers are for physicians and proiders only, not for members, so please don t gie these numbers out to patients. Phone: Fax: Specialists can submit PCP referrals only by paper/hard copy or fax no phone referrals. Mail paper requests, to: P.O. Box 91116, Seattle, WA We encourage use of the CHITA form for submitting requests, as it was designed by Washington state physicians, proider and health plans to simplify administration for all types of proiders and plans. Keeping You In the Loop Here is a list of the News Briefs that hae gone out since our October issue. If you need a copy of any of them, please contact the Proider Relations Team in your region. October: Dispute resolution (complaints and appeals) Noember: 2001 Classic Care changes and benefits summary (Eastern Washington only) Classic Care HCFA encounter data (Eastern Washington only) January: Addiction serices Aoid Denial 190 for Premera HealthPlus Claims If you receie a Premera HealthPlus referral claim denial for reason code 190 (no referral receied, proider write-off) you can either rebill with the referral attached or submit an appeal. As a contractual reminder, if a referral practitioner proides serices without a required referral or outside the scope of the enrollee s PCP referral, then plan or enrollee shall hae no financial responsibility for such charges. Submit claims reprocessing requests in writing. NETWORK NEWS 6

7 For Proiders and Practice Management Helpful Hints Submit claims to the PO box on the back of the member s ID card. Record this information in his/her file for future reference. Check the member s ID card at each isit to make sure you hae current information. Since open enrollment occurs throughout the year, it makes sense to ask patients at each isit if they hae recently changed plans or receied a new card. MAA Billing Instructions on the Web When billing a Medicare claim, you must use the Medical Assistance Administration (MAA) billing instructions. You can access them as follows: 1. Go to the MAA website at 2. Click on Billing Instructions in the blue menu bar. 3. The screen shows that the section of the web for billing instructions is being redesigned, but it can be accessed. Click on Billing Instructions again (in blue bold large font). 4. This takes you to the billing instructions. Contents for all types of billing are listed alphabetically. Click on the applicable item to iew the MAA billing instructions in their entirety. You will need Adobe Acrobat Reader. There is a free download aailable on this page of the site. Or, you can bypass the MAA Home Page and go directly to step 4 (the billing instructions), key in this address: dmn/list%20of%20billing%20instructions.html Send Your Claims on Time Bill us for your serices as soon as possible to receie the best payment turnaround. Eery day you delay submitting a claim adds a day to when you ll receie payment back. So, turn your claims in promptly, and we ll get back to you right away. As a reminder, the deadline for timely filing claims for most managed-care plans is one year from the date of serice (see below for deadlines for the Medicare+Choice product, Classic Care). Please submit bills to us before 12 months pass. If your claim arries after the last date for timely filing, it will reject with an 040 code, telling you it s too late to submit the claim. If you are filing claims electronically, be sure to check these two things: 1. the transmission went through 2. the claim was accepted. To erify, check the Electronic Claims Transaction Report generated by the Premera Blue Cross (PBC) Clearinghouse. This report must be downloaded from the PBC bulletin board. Reports from other clearinghouses, billing serices or from the proiders billing system do not reflect a claims receipt or acceptance. Classic Care Deadlines Deadlines for Classic Care claims are different due to Medicare standards. Claims for serice dates between January 1 and September 30 must be submitted on or before December 31 of the following year. Claims for serice dates between October 1 and December 31 must be submitted on or before December 31 of the second following year. Public Programs The ABCs of Mass Member Communications It s hard to remember all the rules and regulations when you hae a special message to coney to all of your patients. Howeer, when working with public programs such as Basic Health, Healthy Options, Public Employees Benefits Board (PEBB) or our Medicare+Choice plan Classic Care, we both are required to follow certain state and federal guidelines. So be sure to include us in the process. You must send us any materials that will be sent en masse to Premera Blue Cross members. Be sure to gie it to us at least two weeks before the date you plan to print or duplicate the material. We will reiew the piece to ensure it meets contractual and regulatory guidelines, then forward it to the appropriate agency (Health Care Financing Administration (HCFA), Health Care Authority or the Department of Social and Health Serices) for reiew. The agency must approe materials before they can be mailed. We will return their comments and approal to you as soon as we get it. If you hae questions about these guidelines, you may also refer to your Practitioner Manual, or contact your Proider Network Executie or Proider Network Associate. NETWORK NEWS 7

8 PO Box 327 Seattle, WA PRESORTED STANDARD U.S. POSTAGE PAID SEATTLE, WA PERMIT NO Get Connected We hae electronic billing brochures for any physician or proider offices that want to know more about billing electronically. or call her at to request one. Be sure to let her know the region you are calling from. Credentialing Reminder Under all Premera Blue Cross managed-care and indemnity plans, practitioners applying for a contract cannot see members under that contract (or contracts) until they are credentialed and hae receied a countersigned contract back from Premera Blue Cross. If the information submitted in the initial credentialing application is complete, the process typically takes 30 to 60 days. Practitioners may reiew the information submitted in support of their credentialing application at any time by contacting the Credentialing department through their Proider Network Associate. Network News Editor: Western Washington Linda Forrester, , ext Fax: linda.forrester@premera.com Editor: Eastern Washington Keith Pearson, , ext Fax: keith.pearson@premera.com F (1-2001)