Anthem Blue Cross. CCHCA Physician Handbook (7 th Edition) Updated 3/15

Transcription

1 Part II Section B Anthem Blue Cross Introduction 1 Verifying Member Eligibility and Benefits 1 Sample Anthem Blue Cross Member ID Card 2 Anthem Blue Cross Managed Medi-Cal Program 4 CCHCA Physician Handbook (7 th Edition) Updated 3/15

2 Anthem Blue Cross INTRODUCTION Anthem Blue Cross, created in 1986 to provide high quality medical care that is personalized, affordable and accessible, has rapidly grown into one of the largest and most recognized health maintenance organizations (HMO) in California. CCHCA is a participating medical group under Anthem Blue Cross. The addition of Anthem Blue Cross to the existing CCHCA programs will further enhance the access of bilingual providers and quality health care in a culturally sensitive setting to our community. Beginning in May 1, 2014, CCHCA is also a participating medical group under the Anthem Blue Cross Managed Medi-Cal Program. CCHCA utilizes Primary Care Physicians (PCP) for the Anthem Blue Cross Program. The same utilization protocol is used as in our other CCHCA programs. Members who have chosen CCHCA as their medical group must use CCHCA plan physicians for services. Referral physicians must also be from within the medical group. Exceptions require prior authorization from the Utilization Management Department. All claims, and authorizations for Anthem Blue Cross members enrolled under the CCHCA medical group will be processed by the Health Plans Office. Refer to Part I, Section 7 for the mailing address for paper and electronic claims. (Do not submit claims to Anthem Blue Cross. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) The Anthem Blue Cross program also utilizes a co-payment system. The amount to be collected varies for each plan, and should be collected from the patient at the time of service. Some of the member ID cards will carry the amount of the office visit co-payment. Verifying Anthem Blue Cross Member Eligibility and Benefits Eligibility and benefits can be obtained through the Anthem Blue Cross website at If you have any questions concerning patient eligibility, benefits or co-payments, please call Anthem Blue Cross directly at For the Medi-Cal program, please call CCHCA Physician Handbook, Part II, Section B - 1 -

3 Blue Cross Commercial ID cards Identification cards generally provide the following information: 1. Member, spouse, domestic partner or covered dependent name 2. Certificate number 3. Employer group number (for group coverage only) 4. Anthem Blue Cross plan code 5. Coverage code 6. Medical group name, address and phone number (if HMO or POS) 7. Subscriber s effective date with the medical group (if HMO or POS) 8. Additional benefits rider (where applicable) 9. Claims mailing address(es) and Customer Service telephone number(s) for the medical program and any supplemental benefits 10. Instructions regarding carrying and using the identification card 11. Guidelines for obtaining services and reporting emergencies (if HMO or POS) 12. Telephone number for preauthorization or pre-service review (if PPO), this information is not available on the Medicare Advantage ID card CCHCA Physician Handbook, Part II, Section B - 2 -

4 Anthem Blue Cross MEMBER ELIGIBILITY Anthem Blue Cross members enrolled under the CCHCA medical group seeking medical attention and representing themselves as Anthem Blue Cross eligible, but do not possess a valid ID card, should be verified by calling Anthem Blue Cross at Eligibility can also be obtained from the Anthem Blue Cross website at CCHCA Physician Handbook, Part II, Section B - 3 -

5 Managed Medi-Cal Program CCHCA Physician Handbook, Part II, Section B - 4 -

6 Managed Medi-Cal Program Anthem Blue Cross Anthem Blue Cross Managed Medi-Cal Program Anthem Blue Cross was selected by the California Department of Health Care Services and the Department of Public Health to provide health care services for Managed Medi-Cal patients in San Francisco County and other counties in California. Medi-Cal is the second largest source of health care coverage in California and is surpassed only by employer-based coverage. The program provides health care coverage for the most vulnerable low income citizens who lack health insurance. Anthem was the original Medi-Cal Managed Care Organization and continues to be Medi-Cal s largest health plan provider. CCHCA and Anthem Blue Cross Managed Medi-Cal Program CCHCA is a participant in the Anthem Blue Cross Managed Medi-Cal Program beginning May 1, Beneficiaries choosing CCHCA will make a choice of physician-hospital. CCHCA will pay claims based on the Medi-Cal fee schedule for professional services. CCHCA physicians will be listed in the Anthem Blue Cross Medi-Cal directory under the CCHCA Medical Group. All claims, and authorizations for Anthem Blue Cross Managed Medi-Cal members enrolled under the CCHCA medical group will be processed by the Health Plans Office. Refer to Part I, Section 2 for the mailing address for paper and electronic claims. (Do not submit claims to Anthem Blue Cross. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) CCHCA Physician Handbook, Part II, Section B - 5 -

7 As of May 1, 2014, Anthem Blue Cross Managed Medi-Cal Members can choose CCHCA as their Medical Group. Members will receive a welcome letter and a new ID card from Anthem Blue Cross after enrollment. The new ID card will identify CCHCA as the medical group, PCP name, PCP address and PCP phone number. Below is a sample Anthem Blue Cross Medi-Cal Program ID card: Anthem Blue Cross Managed Medi-Cal Program ID Card (Front) Anthem Blue Cross Managed Medi-Cal Program ID Card (Back) CCHCA Physician Handbook, Part II, Section B - 6 -

8 Anthem Blue Cross Managed Medi-Cal Program MEMBER ELIGIBILITY How to Verify Anthem Blue Cross Managed Medi-Cal Member Eligibility Medi-Cal members will receive a State Beneficiary Identification Card (BIC) from the Department of Health Care Services (DHCS). The BIC contains eligibility information that is accessible when providers swipe the card in their Point-Of-Service (POS) device before each visit. In addition to the State-issued BIC card, Anthem Blue Cross provides each member with an identification card. Anthem will issue ID cards within seven (7) days from receiving the enrollment file from the State. Providers must verify eligibility before rendering services. Providers can verify eligibility: 1) With the State of California: 24/7 Automated Eligibility Voice System (AEVS) Swipe the BIC card with a Point of Service (POS) device Using the Certified Eligibility Real Time Systems (CERTS) 2) With Anthem Blue Cross: Availity at 8am 7pm EST or call Call Blue Cross s 24/7 Interactive Voice Response (IVR) at Eligibility verification can also be obtained through the: 24/7 NurseLine: or (TTY) Submitted claims do not guarantee payments. Payment is subject to patient eligibility. Be sure the patient s eligibility is current before rendering service. CCHCA Physician Handbook, Part II, Section B - 7 -

9 Blue Cross Managed Medi-Cal Benefits and Services: Coordination of Care Initial Health Assessments (IHA): For new members under 18 months of age, within 60 days of enrollment. For new members 18 months and older, within 120 days of enrollment. Physician office visits -- inpatient and outpatient services Durable medical equipment and supplies Emergency Services Pharmacy benefits by Express Script, Inc. Benefit Change - Once members transition to Medi-Cal, they will no longer have the mail-order prescription benefit. Detailed benefits/services information is available in the Provider Manual located on the Anthem Blue Cross Provider website at Select State Sponsored plans/provider Manuals. Vision and Dental Services 1) Vision Services: Vision services (including yearly diabetic retinal exams) will be available through vision doctors in the Medi-Cal health plan. The provider directory included in the member s Welcome packet will include all medical and vision doctors. Medi-Cal members access basic vision care services through Vision Service Plan (VSP) providers. Providers contact: VSP Provider Service Support Line for questions, or visit the VSP website at 2) Dental Services: Children enrolled in Medi-Cal will receive dental services through Denti-Cal, a Medi-Cal FFS dental program. CCHCA Physician Handbook, Part II, Section B - 8 -

10 Members with questions about the dental coverage can contact the Denti-Cal Beneficiary Customer Service line at Sensitive Services Members may self-refer for the following services without a referral, within or outside of the Anthem Network: Family Planning Sexually Transmitted Infections (STIs) HIV Testing and Counseling Sexual assault Drug or Alcohol abuse for 12 years of age and up Abortion Initial Health Assessment (IHA) PCP s must provide new members 18 months and older with an initial health assessment (IHA) within 120 days from the member s effective date. Members under 18 months of age should be provided with an IHA within 60 days of enrollment. Pregnant women should have their IHA as soon as an appointment can be scheduled. The IHA should follow appropriate preventive health guidelines and should include a physical examination with referrals for lab work and tests as indicated, immunizations, anticipatory guidance, and a nutritional assessment. Staying Healthy Assessment (SHA)/Individual Health Education Behavioral Assessment (IHEBA) In addition to an IHA, the Staying Healthy Assessment (SHA) tool must also be completed and periodically be readministered according to the SHA periodicity chart. The SHA is an age-specific risk assessment tool that is repeated at specific age intervals. It is used to assess a member s health habits and status, such as nutrition, physical activity, environmental safety, and sexual health and substance use as appropriate. The SHA/IHEBA forms can be found in the forms library on the Provider Resources page in the Blue Cross website at: CCHCA Physician Handbook, Part II, Section B - 9 -

11 State and County Services and Programs Anthem Blue Cross Below are some State and County resources that are available to Medi-Cal patients. It is not intended to be a comprehensive list. Additional information on programs available could be obtained through the Provider Manual located on the Anthem Blue Cross Provider website at Select State Sponsored plans/provider Manuals. California Children s Services (CCS) CCS is a state and county funded program that serves children under the age of 21 who have acute and chronic conditions that may benefit from specialty medical care and case management. These services are available to all medically eligible children under the age of 21, including those who are Medi-Cal eligible. Providers who encounter children with certain CCS covered conditions must refer the children to the appropriate CCS regional office. California ChiIdren's Services offers services to children and young adults with the following conditions: AIDS Cancer Cataracts Cerebral palsy Chronic kidney disease Cleft lip/palate Congenital heart disease Diabetes Hearing loss Hemophilia Intestinal disease Liver disease Muscular Dystrophy Rheumatoid arthritis Seizures Severe burns Severe crooked teeth Severe head, brain or spinal cord injuries Sickle cell anemia Spina bifida Thyroid conditions Tumors CCHCA Physician Handbook, Part II, Section B

12 To contact CCS, please go to the program website to find the phone and fax numbers for the appropriate county CCS office at: Assistance in identifying CCS covered conditions or referring members to the appropriate CCS regional site can also be obtained from the UM Case Management Department. For a complete listing of CCS providers, please go to: CCHCA Physician Handbook, Part II, Section B

13 Child Health and Disability Prevention Program (CHDP) What is the Child Health and Disability Prevention Program (CHDP)? CHDP is a California state program that provides preventive health assessment services and referrals for diagnosis and treatment of suspected problems for children and youth who are Medi- Cal recipients from birth to 21 years of age, for non-medical eligible children from birth to 19 years of age, and children enrolled in Head Start and State Preschool Programs. Services offered by CHDP include growth and development check, immunizations, dental screening, vision screening, hearing screening, nutrition check-up, health education, tobacco education, and WIC referral for children to Age 5. For more information on CHDP, visit the state CHDP site at: For a complete listing of CHDP providers in San Francisco, please go to: CCHCA Physician Handbook, Part II, Section B

14 Comprehensive Perinatal Services Program (CPSP) The CPSP is a Medi-Cal reimbursement program that provides a wide range of services to pregnant women, from conception through 60 days postpartum. Medi-Cal providers may apply to become approved CPSP providers. In addition to standard obstetrical services, women receive enhanced services in the areas of nutrition, psychosocial and health education from approved CPSP providers. For more information on CPSP, please call or visit: Behavioral Health Services Behavioral Health Services are provided through the San Francisco Community Behavioral Health Services (SFCBHS). SFCBHS services include assessment, diagnosis, and treatment for an array of mental health and/or substance abuse problems. The Phone number for SFCBHS is Providers can also call Blue Cross Medi-Cal Customer Care Center at: for additional information on Behavioral Health Services. Vaccines for Children (VFC) The vaccines for children program provides free vaccines to enrolled providers for administration to children eligible for Medi-Cal, CHDP, or to uninsured children ages Providers must enroll with VFC to receive the vaccines by mail for Medi-Cal patients. Vaccines provided include: Hepatitis A vaccine, Haemophilus Influenzae b vaccine, Human Papilloma Virus vaccine, Influenza vaccine, Pneumococcal vaccine, DTP, DTap, MMR, MMRV, Varicella vaccine, Meningitis Vaccine, and Hepatitis B Vaccine. For more information on the VFC program, please call or visit: Women, Infants and Children Program (WIC) The Women, Infant and Children Program (WIC) is a supplemental nutrition program that helps pregnant women, new mother and children under 5 eat well and stay healthy. Services include free food vouchers, nutritional counseling and breastfeeding support. For more information on the WIC Program, please call WIC-WORKS ( ) or visit the WIC website at: CCHCA Physician Handbook, Part II, Section B

15 Claims Submission Guidelines For the Blue Cross Medi-Cal Program The following protocol should be followed when submitting Blue Cross Medi-Cal claims: 1. All claims for payment are to be submitted on CMS 1500 forms with the appropriate CPT, HCPS or Medi-Cal only codes when applicable. 2. Use the Anthem Bluecross member ID number when submitting claims. Do not use the beneficiary s Medi-Cal number. 3. Submitting Claims Refer to Part I, Section 7 for the mailing address for paper and electronic claims. (Do not submit claims to Anthem Bluecross. This will only cause delay in payment of your claims, as the claims will be returned to our office for processing. ) 4. For questions regarding Anthem Bluecross claims, please call the claims Department at (415) Sterilization Claims: Claims for sterilization must be submitted on CMS 1500 using appropriate CPT, HCPS or Medi-Cal only codes. The physician must keep a copy of the completed sterilization consent form PM330 on file in the office. CHDP Claims: Claims for CHDP services are to be submitted on CMS 1500 using CHDP codes. A CHDP form PM160 PHP must also be completed and submitted along with the claim. The PM160 form is collected by the State and Local CHDP offices for administrative purposes. Maternity Claims: Claims for prenatal and maternity services are to be billed on CMS 1500 forms using the appropriate CPT, HCPS, and/or Medi-Cal only codes. Maternity services may be billed using global maternity codes, unless total OB care had not been rendered. In these instances, claims received using global maternity codes must be mailed back to the submitting provider with a request to re-code and resubmit the claim using itemized codes. CPSP Claims: If a certified provider, CPSP services must be billed using CPSP specific procedure codes. CCHCA Physician Handbook, Part II, Section B

16 Family Planning and Sensitive Services Claims: Claims for consultation for Family Planning services and STD services must be submitted on CMS 1500 using the appropriate CPT, HCPCS, or Medi-Cal only codes. CCHCA Physician Handbook, Part II, Section B