2017 Qualified Health Plans Educational Webinars. Frequently Asked Questions (FAQ) from sessions held week of: 1/23/2017 1/27/2017

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1 2017 Qualified Health Plans Educational Webinars Frequently Asked Questions (FAQ) from sessions held week of: 1/23/2017 1/27/ Do the reference or certification numbers of the referral need to be added to a claim? 2. Do we need to have a patient sign an Advanced Beneficiary Notice (ABN) for services performed without a referral? Will services performed without a referral go to the patient s out-of-network benefits? 3. We have several providers in our clinic. If we receive a referral for one provider, can the patient see any of our providers? 4. What if the PCP enters CPT code on the referral but we need to bill a 99204? Since these codes don t match, will our claims still pay as in-network? 5. How long are authorizations good for? 6. We are an OB/GYN office and have a patient who is a Mountain View network member and she has gone into pre-term labor. What happens if we send her to Eastern Idaho Regional Medical Center and they are not in-network with her plan? Her baby will more than likely be in the NICU as she is only 35 weeks along. Will she and her baby be covered as in-network since this is an urgent situation? 7. Will a gap referral be approved for an out-of-network specialist if there is an in-network specialist available? 8. If we need to send a patient for lab work, can a specialist send a referral for this or does the PCP have to? 9. Will we need a referral for outpatient physical therapy in 2017 even if the patient began treatment in 2016? 10. How long does it take for a referral issued by a PCP to be visible in JIVA? 11. Is Bingham Memorial Hospital in-network with the Connected Care Portneuf Quality Alliance (PQA) network? 12. Many patients have not received their new ID cards. When can we expect to see them? 13. What if we have a patient who wants to see an out-of-state provider, could a gap referral be approved? What if that provider does not contract with Blue Cross? 14. Is the certification number on a referral the number that we use? 15. Is there a way to check online which CPT codes will pay for each client for mental health services?

2 16. How long does it take get the third-party eligibility verification software updated? For example, Passport shows the patient s insurance for 2016 but is not showing for 2017 for several patients. 17. We are an OB/GYN office. If we are not the patient s PCP, can they self-refer to us for a problem that may result in surgery? 18. We are an OB/GYN provider but are not the patient s PCP. If this patient needs to be referred to a cardiologist, do we do the referral or must that come from the PCP? 19. How do we opt out of being a PCP? 20. Even if we opt out of being a PCP, as an OB/GYN office, can we still provide care without a referral 21. Are these webinars recorded and will they be available to view on line at a later time? Answers 1. Do the reference or certification numbers of the referral need to be added to a claim? No. Specialists need to add the name of the patients PCP and the PCP s NPI number to box 17 and 17 B of the claim form respectively. Any numbers associated with the referral should not be attached to a claim. 2. Do we need to have a patient sign an Advanced Beneficiary Notice (ABN) for services performed without a referral? Will services performed without a referral go to the patient s out-of-network benefits? Services provided will be processed as a benefit determination; benefits will either be applied to the patient s in-network benefits or out-of-network benefits. Obtaining an ABN is not necessary. Services performed without a proper referral in place may process to a patient s out-ofnetwork deductible? 3. We have several providers in our clinic. If we receive a referral for one provider, can the patient see any of our providers? Yes. Referrals must be issued to a specific provider however, if another provider of the same specialty-type that practices under the same Tax Identification Number (TIN) may use the referral. If there are multiple specialists in the same office that have different TINs, then they would require a separate referral. Referrals are approved for specialty types and TINs. For example, if a referral is issued for Dr. Kent for gastroenterology but Dr. Wayne, who is also a gastroenterologist and practices under the same TIN, can see the patient sooner, that referral would also be valid for Dr. Wayne. Conversely, if a referral is

3 issued to Dr. Kent, but Dr. Wayne in the same office, practices under a different TIN could see the patient sooner, Dr. Wayne would need his own referral. 4. What if the PCP enters CPT code on the referral but we need to bill a 99204? Since these codes don t match, will our claims still pay as in-network? Yes. CPT code for referrals has been configured in our systems to allow the referrals, especially referrals to in-network specialists, to approve automatically. CPT is simply used as a placeholder; it does not limit the specialist s billing in any way. 5. How long are authorizations good for? Authorizations are valid through the end date specified by the entity that approved that authorization request, i.e.-aim, Blue Cross of Idaho Healthcare Operations, etc. Referrals are valid through December 31, 2017 or less, depending on the end date entered by the PCP. Remember that referrals and authorizations are different. Referrals are for provider to provider; authorizations are for proving medical necessity. 6. We are an OB/GYN office and have a patient who is a Mountain View network member and she has gone into pre-term labor. What happens if we send her to Eastern Idaho Regional Medical Center and they are not in-network with her plan? Her baby will more than likely be in the NICU as she is only 35 weeks along. Will she and her baby be covered as in-network since this is an urgent situation? Because of the urgency of this type of scenario, both the patient and her baby will receive in-network benefits regardless of the facility they received care. Urgent and emergent care will process for in-network care regardless of where that care is rendered. Eastern Idaho Regional Medical Center does not contract with any of the 2017 tailored network plans however; any care they provide for urgent and emergent cases would process in-network. To view Blue Cross of Idaho s definition and criteria of urgent care, please refer to Provider Administrative Policy (PAP) Will a gap referral be approved for an out-of-network specialist if there is an in-network specialist available? If the out-of-network specialist can provide a service that the in-network specialist cannot, this would need to be communicated to Blue Cross of Idaho in Step 6 of the referral process. If an in-network specialist can perform the same service that the outof-network specialist can, then a gap referral for this scenario would not be approved. For example, if the patient in the CarePoint network needs a heart transplant, but none of the cardiologists in the CarePoint network perform heart transplants, but a cardiologist in the Connected Care Saint Alphonsus Health Alliance does perform them,

4 then this would need to be communicated in the referral process so that Healthcare Operations can issue a gap referral. 8. If we need to send a patient for lab work, can a specialist send a referral for this or does the PCP have to? Lab services do not require a referral as long as the lab provider is in-network. Any provider that needs to order lab work for a patient may do so. For a list of services that do not require a referral, please select here. Remember, only PCPs may issue referrals for specialists or non-pcp provider types that require them. Specialists are not allowed to issue referrals. 9. Will we need a referral for outpatient physical therapy in 2017 even if the patient began treatment in 2016? Physical therapy does not require a referral as long as the physical therapy provider is within the patient s network. For a list of services that do not require a referral, please select here. 10. How long does it take for a referral issued by a PCP to be visible in JIVA? For a properly-entered referral by a PCP to in-network specialist will be approved in a matter of minutes. Gap referrals, or referrals requesting an out-of-network provider, will review additional review by Healthcare Operations and will take longer, potentially days. 11. Is Bingham Memorial Hospital in-network with the Connected Care Portneuf Quality Alliance (PQA) network? No. Bingham Memorial Hospital is not currently contracting with any of the QHP tailored networks. However, Bingham Memorial Hospital would still be able to provide care for patients that needed urgent or emergency services and those services would process as in-network. Bingham Memorial would also be able to provide services with an approved gap referral. 12. Many patients have not received their new ID cards. When can we expect to see them? If a patient presents to your office without an updated ID card, either they are not presenting you with their most current card or they have not paid their premium. The provider portal will have the most updated card information and these cards images may be printed. Always be sure to verify a patient s eligibility. If their premiums are up-to-date, their policy ID number should be visible.

5 13. What if we have a patient who wants to see an out-of-state provider, could a gap referral be approved? What if that provider does not contract with Blue Cross? If a patient wants to see an out-of-state provider, an approved gap referral would be required in order for the patient to receive in-network benefits. However, if the care that the patient needs could be provided in-state, even if it would be out-of-network, it would be unlikely that the out-of-state referral would be approved unless there were extenuating circumstances. If a patient chooses to see a non-contracting out-of-state provider, even with an approved gap referral, they should expect to be balanced-billed for any charge above what their benefits would cover. 14. Is the certification number on a referral the number that we use? Yes, the certification number or the reference number is a valid way to reference a referral. However, it is not necessary to attach this certification/reference number to a claim. If you are a specialist, please enter the patient s PCP name and NPI in box 17 and 17b of the claim form or its electronic equivalent. 15. Is there a way to check online which CPT codes will pay for each client for mental health services? Always remember to check a patient s benefits through the provider portal. After signing on, hover over the Eligibility & Claims tab and select Member Search. Next, enter the member s last name and date of birth or the Enrollee ID if you have it and select Search. A list of policies will then appear and you may select the policy that is active which will show the Eligibility Information page. From here, select Benefit Information from the list on the left side of the screen. You may then select the Mental Health & Substance Abuse Services from the accordion list. No specific CPT codes will be shown but this will provide a summary of the patient s benefits. 16. How long does it take to get the third-party eligibility verification software updated? For example, Passport shows the patient s insurance for 2016 but is not showing for 2017 for several patients. Patient s eligibility should be updated in real-time so for those eligibility verification software programs that are enabled to report the 270/271 transactions, current eligibility results should be visible. If no 2017 member eligibility is showing, most likely the member s premiums have not been paid and the plan has not yet been effectuated. 17. We are an OB/GYN office. If we are not the patient s PCP, can they self-refer to us for a problem that may result in surgery? Yes. Because OB/GYNs may also provide primary care, a referral from a patient s PCP is not required as long as the OB/GYN is in-network with the patient s plan.

6 18. We are an OB/GYN provider but are not the patient s PCP. If this patient needs to be referred to a cardiologist, do we do the referral or must that come from the PCP? Only a patient s PCP may enter referrals. It is the intent of the new Qualified Health Plans that the PCP be the cornerstone of the patient s care. Information should always be communicated back to the patient s PCP. 19. How do we opt out of being a PCP? To opt out of being a PCP, you must complete a Provider Update Form to notify Blue Cross of Idaho your desired change. Panel updates require 30-day written notice. For more information, please refer to PAP Even if we opt out of being a PCP, as an OB/GYN office, can we still provide care without a referral? Yes. As long as you are within the member s network, you may still provide primarytype care as an OB/GYN provider. 21. Are these webinars recorded and will they be available to view on line at a later time? Each webinar is recorded and a copy of the recording will be made available upon request to those who have attended. To request a copy of the webinar, please reply to either your invite to the WebEx or to the survey request sent at the end of each week. Special Reminder: The changes discussed above only apply to the Affordable Care Act (ACA) plans purchased through the healthcare exchanges, insurance brokers, or through the shopper s page on the Blue Cross of Idaho website for individual members and their family. Large commercial insurance plans that are furnished through employer groups such as Albertson s or Simplot for example, will not be affected by these changes.

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