one one Three Ways to Identify a Medicare Advantage Plan Member Reminder to Sign Up for EFT Direct Data Entry Now at Blue Cross of Idaho

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1 SPRING 2014 Reminder to Sign Up for EFT We still have offices who have not signed up for Electronic Funds Transfer (EFT) through the Blue Cross of Idaho provider website at bcidaho.com/provider. Enrollment is quick and easy and EFT payments save office administrative time, save travel to and from the bank, and ensure automatic deposit on the same day every week. To register your office for EFT payments, log on to the provider portal at bcidaho.com and complete an EFT agreement located under Remittance Information. Once you submit a completed form, bank verification and processing takes about 10 business days before your office begins receiving EFT payments. Note: To enroll, your office must be registered as a provider at bcidaho.com. Once enrolled in the EFT program, you will no longer receive paper remits and will access your remits from the provider portal. If your office receives an electronic 835, that process will remain unchanged. The designated contact on the registration form will receive EFT payment vouchers via . You can also view your office s payment vouchers online for future retrieval. Three Ways to Identify a Medicare Advantage Plan Member Check the Medicare Advantage ID card. Medicare Advantage member numbers begin with: XMM True Blue HMO XMI True Blue Connected Care HMO POS XMX True Blue HMO Special Needs Plan XMA Secure Blue PPO Verify eligibility online through the secure provider portal of Blue Cross of Idaho s website at bcidaho.com. Call Blue Cross of Idaho to verify eligibility (see MA PAP 102). Start automating! Register Today! Direct Data Entry Now at Blue Cross of Idaho Coming June 1, 2014, Blue Cross of Idaho is pleased to announce Direct Data Entry! With a user ID and password for our website, bcidaho.com, you will soon be able to directly bill your Blue Cross of Idaho professional medical claims. No software required! Please watch for upcoming correspondence pertaining to this valuable tool to schedule training with your External Provider Relations Representative. TO one one FOR HEALTHCARE PROFESSIONALS

2 OCTOBER Provider Credentialing Required To comply with healthcare reform requirements, Blue Cross of Idaho must credential all new and current providers contracted under a PPO agreement. Months ago, we began issuing general statewide provider alerts soliciting credentialing applications, but we are now targeting communications to contracting providers who are not yet credentialed. Provider Alerts will be issued to clinics that employ providers currently covered under a PPO contract who are not yet credentialed. A credentialing application must be completed and returned for each provider listed. The packet needs to be completed once for each provider, not once for each service location. Hospital-based providers without private practices (i.e. anesthesiologists, radiologists and pathologists) are not required to submit credentialing packets. Providers not credentialed may lose their PPO contracting status with Blue Cross of Idaho and may be termed December 1, To obtain a credentialing application: Go to bcidaho.com/providers/provider Packet Select the Contracting link for your specific provider type Select Credentialing Application to open and print the document Attach all the required supporting documentation to the completed application and submit it via to PR2PI@bcidaho.com or fax at If you have any questions, please contact the provider relations representative in your service area. Refer to Provider Administrative Policy 100 for a listing of area representatives. Blue Cross of Idaho must receive completed applications, including all required attachments, NO LATER THAN OCTOBER 1, PPO contracting providers who do not return complete applications may lose contracting status with Blue Cross of Idaho. 2

3 Compare Your Cost and Utilization Against Idaho Peers Blue Cross of Idaho has adopted a reporting tool designed to allow physicians to compare their cost and utilization practice patterns for commonly treated conditions to their Idaho peers practicing in the same specialty. Reports are compiled from commercial claims data submitted to Blue Cross of Idaho and exclude claims from Federal Employee Plan and Medicare Advantage. The reports are not intended as a statement of physician ability or quality, but solely as a means to relate the relative cost efficiency of each physician within his or her specialty peer group. Ten specialties Family Practice, Internal Medicine, Pediatrics, Orthopedic Surgery, General Surgery, Otolaryngology (ENT), Obstetrics and Gynecology, Gastroenterology, Cardiology, and Urology received the first version of these reports, which was distributed in February. The next iteration of reports will include specialties such as Emergency Medicine, Dermatology, Ophthalmology, and others. Key Details Beginning May 1, clinic scores are available on the Blue Cross of Idaho secure website. Scores will be listed under Key Performance Indicators and will be periodically updated as our data set is refreshed. Reports are based on cost and utilization for a 12-month period. A performance score of 1.00 reflects the peer group average. A score of <1.00 indicates costs for treating common conditions are lower than the average for the specialty. A score >1.00 indicates costs are higher than the average for the specialty. Scores are adjusted for patient complexity including patient age, gender and comorbidities. We plan to include this measure to differentiate physician payment in the near future. If you have any questions, or wish to schedule a meeting to discuss this information and review the details, please contact Becki Wallace, Health Systems Performance Specialist at (208) or bwallace@ bcidaho.com. Handling Customer Complaints At Blue Cross of Idaho, our member s concerns are important to us. We invite our members to let us know if they have a concern about or complaint against one of our practitioners or their office staff. We track complaints, monitor them on a regular basis, and, if necessary, contact the practitioner for more information about an event. Common provider complaints: Member felt the practitioner made errors Member felt the examination was not comprehensive or the practitioner rushed through the appointment Member felt charges did not equal services received or had other billing concerns Member felt practitioner and/or practitioner s office staff were unprofessional If a complaint is made against you or your office, we provide you an opportunity to respond. We encourage you to respond as requested. This helps us better understand the circumstances of the incident from a complete perspective. 3

4 Annual Idaho Health Care Conference The 21st Annual Idaho Health Care Conference (IHCC) is coming to a town near you and Blue Cross of Idaho is pleased to offer Idaho providers the following classes: 2014 Website Updates 8:30 9:30 a.m. Learn about the new features on our provider website and explore resources and tools available at your fingertips. Various time-saving electronic processes will be reviewed. Join us to learn how to make the most of Blue Cross of Idaho s online information. Provider Relations Updates a.m. This session addresses the provider issues that generate the highest volume of phone calls and inquiries. We will discuss how to minimize these calls and provide an explanation of our business practices. Topics include Provider Enrollment and Set Up, Credentialing Requirements, Claims Filing and Medicare Advantage Dual Special Needs Plan / Medicare Medicaid Coordinated Plan. ICD-10-CM Objectives (presented by the Idaho Medical Association) 11:15 a.m. 12:15 p.m. Improve your odds and win the jackpot with ICD- 10-CM preparation! This class includes information on ICD-10 guidelines including a brief orientation of ICD-10-CM with an ICD-9-CM comparison as well as clinical documentation gap analysis, practice coding, office preparation and payer readiness. Healthcare Fraud, Waste and Abuse 1:30 2:30 p.m. Blue Cross of Idaho Special Investigations Unit will teach about fraud, waste and abuse issues commonly experienced by payers and will cover areas of risk for the provider, federal education requirements for providers participating in federal programs, and summaries of recent cases. Provider Network Management & Medicare Advantage 3 4 p.m. This session will provide an overview of upcoming contracting efforts including the expansion of credentialing, development of narrow networks, and Accountable Care Organizations. Session will also include an update on Medicare Advantage Plans, including the new Medicare Advantage Dual Eligible Special Needs Plan and its expanded services including long term support services, long term care, the expanded mental health benefit, and care coordination. View the entire program brochure at bcidaho.com/providers. Register online at surveymonkey.com/s/8h9l36p. IHCC Schedule Idaho Health Care Conference Lewiston Tuesday, May 6 Register by April 29 Red Lion Boise Tuesday May 13 Register by May 2 Doubletree Hotel Riverside Pocatello Wednesday, May 21 Register by May 14 Clarion Inn Coin of Excellence Coeur D Alene Wednesday, May 7 Register by April 30 Best Western CDA Idaho Falls Tuesday, May 20 Register by May 13 Shilo Inn Burley Thursday, May 22 Register by May 15 Best Western Burley Inn 4

5 ConnectedCare sm A Narrow Network Option Now that open enrollment on the Health Insurance Exchange has come to a close, Blue Cross of Idaho has a substantial number of new members enrolled in our plans, including our newest product option ConnectedCare SM. Six managed care plans of varying benefit levels, available in the Treasure Valley through the Saint Alphonsus Health Alliance (SAHA) and Eastern Idaho through the Portneuf Quality Alliance (PQA), seek to provide members higher quality and better coordination of care at more affordable prices. Our ConnectedCare plans are Bronze Connect, Silver Connect, Silver Connect No Deductible, Gold Connect, Platinum Connect and a catastrophic plan for members under 30 called Covered Connect. These plans have some different characteristics than our other PPObased products; most notably are the high performance networks that support them are geographically limited to certain areas of the state. ConnectedCare also requires members to select a Primary Care Provider (PCP) and obtain referrals to see specialists. For benefit information about Blue Cross of Idaho s individual medical product offerings on the Health Insurance Exchange, including ConnectedCare plans, please visit shoppers.bcidaho.com. About the Plans Connect plans have unique alpha prefixes of XMD, XMN, XMO or XMU and a ConnectedCare logo on their member ID card. Member ID card samples may be found in Provider Administrative Policy (PAP) 102 at bcidaho. com. You can identify the applicable ConnectedCare network by the Idaho Provider Network acronym and accent color on the member ID card. Saint Alphonsus Health Alliance serves ConnectedCare members in six counties within southwestern Idaho and eastern Oregon, including Ada, Canyon, Gem, Payette, Washington and Malheur Portneuf Quality Alliance serves ConnectedCare members in two counties within Eastern Idaho, including Bannock and Bingham Provider Participation If you are a Primary Care Provider (PCP) for one our Connect plans and you are no longer accepting new patients, please notify your Provider Relations representative as soon as possible. This allows us to close your panel so new members are not able to select you as their PCP, unless you instruct us to do so in special circumstances. If you are NOT in either ConnectedCare network (SAHA or PQA) and a Connect plan member presents to your office, kindly inform them that you are not in their network so they understand that benefits for your services will likely be paid at a lower level and they will owe a larger out-of-pocket cost share. If you are interested in participating with ConnectedCare, you must contact the network administrator for SAHA or PQA accordingly, as provider network participation and management has been delegated to them. Referrals ConnectedCare members MUST have a valid referral on file with Blue Cross of Idaho to see a specialist. If you are a SAHA or PQA network provider and have questions about referral guidelines, the process for submitting referrals, please reference PAP 635 at bcidaho.com for more information. ConnectedCare referrals are required to stay within the appropriate network, unless there is a gap in available network services, in which case a referral to an out-ofnetwork provider will be accepted. To verify network participation for both SAHA and PQA, visit our provider search tool on the web or go directly to bcidaho.com/ SaintAlphonsus or bcidaho.com/portneuf. Verify referrals via the provider web portal within the Jiva authorizations/notifications program. Please contact your Provider Relations representative if you are unable to locate this information or still have questions. Refer to PAP 100 on our website at bcidaho.com to locate your Provider Relations representative. 5

6 Three-Months to Pay: What Billing Needs to Know About Grace Periods. The Affordable Care Act says individuals buying health insurance through an online exchange who receive a tax credit (also called a subsidy) also have a three-month grace period to pay outstanding premiums. During this time, insurers cannot disenroll members for non-payment of premiums and must pay claims incurred during the first month. However, claims incurred during the second and third months of the grace period will be held in a pending status until the member pays the premium in full. What does this mean to you? While we hold claims incurred during the second or third month of a member s grace period in pending status, providers may collect the full customary charges for any services rendered to the member during that time period. When will claims be processed? If a member pays in full by the end of the grace period We will process any pending claims in accordance with the terms of the member s policy. If you collected for a charge at the time of service, you must refund the member any collected amounts beyond the member s cost share within 30 days of receiving payment from Blue Cross of Idaho. Please note that if you do not provide a timely refund to the member, you could be in breach of your provider contract. If the member does not pay in full by the end of the grace period We will deny any pending claims with dates of service during the second and third months of the grace period. You may seek full reimbursement directly from the member for the services provided. How will you know if a member is delinquent? Blue Cross of Idaho will identify members with a delinquent status in two different ways: First, log into Blue Cross of Idaho s secure medical or dental provider portal from bcidaho.com and select Eligibility & Claims. For Pre-Service Queries: o Select BCI Member Search and enter the member s ID number. o The Status column will display Delinquent if the member is in the second or third month of delinquency. For Post-Service Queries: o If a submitted claim is pending, select the claim to get detailed information. For Blue Cross of Idaho insured members, the message will read, This member is APTC premium delinquent. o For BlueCard members, the message will read, This member is APTC premium delinquent month 3. In addition, it will include the name of the member s home plan and a phone number for eligibility questions. 6

7 Quality Measures Checklist As the practice of medicine continues to evolve, quality measures are increasing in prominence. The following provider checklist summarizes some of Medicare s quality measures and is divided into sections for general measures, age-specific measures and disease-specific measures. Please consider meeting applicable checklist items with each of your Medicare patients. Blue Cross of Idaho collects data about these measures from multiple sources, including medical records, claims and patient surveys, then uses an audit methodology and annually reports the results to Medicare. Please note: The checklist does not address conditions that would exclude patients from screening, e.g. a mammogram is not required for a woman in the age bracket who has had a bilateral mastectomy. o (All) Flu Shot Received o (All) Record Body Mass Index (BMI) Medicare Provider Checklist o (50-69) F, Mammogram in past 2 years o (50-75) Colorectal Cancer Screen o (65+) No High Risk Medication Prescription (Refill) o (65+) Urine Leakage, received treatment o (65+) Problems with balance, received intervention o (65+) Advised about physical activity Diabetes o (18-75) LDL Chol test o (18-75) Retinal exam o (18-75) Nephropathy test o (18-75) Hemoglobin A1c of 9 or below o (18-75) LDL < 100 mg/dl o (18+) If on diabetic med, RAS antagonist Rx filled o (18+) Fill diabetic medication at least 80% of time Heart Disease o (18-75) LDL Chol test Hypertension o (18-85) BP Both numbers less than or equal to 139/89 o (18+) Fill RAS antagonist medication at least 80% of time If you have questions, feel free to contact me, Lance W. Coleman, MD, Senior Medical Director, at (208) High Cholesterol o (18+) Fill statin cholesterol medication at least 80% of time Rheumatoid Arthritis o Disease Modifying Anti-rheumatic Drug (DMARD) Rx filled once Fracture any bone, during survey year o (67+) F, Within 6 months, Bone Mineral Density Test or Osteoporosis Rx For Your Information, the Member Survey Asks the Member: Able to get appointment when felt it was needed? o Yes o No Get tests and treatment when needed? o Yes o No Seen within 15 minutes of appointment time? o Yes o No Provider has needed records? Test results? o Yes o No Provider aware of most recent specialist visits? o Yes o No Provider discussed prescription medications? o Yes o No An Independent Licensee of the Blue Cross and Blue Shield Association 7

8 A Health Plan for those with Idaho Medicaid and Medicare Our True Blue SNP SM plan provides coverage for Idahoans enrolled in Medicare and Medicaid services. True Blue SNP covers long-term services and support.* Participating members are issued one Blue Cross of Idaho identification card for all plan services, and our customer service team is available to assist them seven days a week. In addition to medical coverage, True Blue SNP provides: Preventive and restorative dental coverage Vision coverage A care manager A gym membership** $0 Premium $0 Part D Deductible $0 Copay for services HOW DOES TRUE BLUE SNP BENEFIT MY PRACTICE? You probably help many people who hold two, three or even four different health insurance plans. All these plans with different policies and procedures may cause confusion for your clerical staff. Now, imagine most of your patients holding one health insurance plan, with one customer service team ready to help your staff when necessary. We designed True Blue SNP not only around your patient s needs, but the needs of your practice. WHAT IS A CARE MANAGER? A care manager acts as a liaison between your patient, his or her family and his or her care providers to ensure everyone has access to the information they need to provide the best care and support for the member. Simply put, care managers work with members and all of the people associated with their care to ensure they have access to timely care that is appropriate for their condition and the highest quality. WHO IS ELIGIBLE FOR TRUE BLUE SNP? You may work with a number of people who could benefit from True Blue SNP. Your clients may qualify if they are enrolled in a state of Idaho Medicaid plan, have Medicare Parts A & B, are at least 21 years old and live within our service area. Currently, we offer True Blue SNP in 33 Idaho counties. Enrollment is voluntary. There is no open enrollment period and members can opt out at any time. NEED MORE INFORMATION? To learn more about True Blue SNP, ask questions or to become a contracted provider, please call us at or TTY Learn more online at truebluesnp.com. Our trained customer representatives are available from 8 a.m. to 8 p.m., 7 days a week.. * Long-term support includes A&D waiver services, Intermediate Care Facilities for people with intellectual disabilities (ICFs/ID), nursing homes, assisted living facilities, and targeted service coordination for individuals on the development disabilities waiver. ** Members who qualify are eligible for an attendant while at the gym; $50 annual copayment applies to gym membership. Medicare Advantage Plans True Blue Special Needs Plan (HMO SNP) 8

9 New Faces Sheila Habblett recently joined our team of Provider Network specialists. She has been with Blue Cross of Idaho for eight years, previously in claims processing and auditing. She has lots of experience working in provider offices and has also worked as a sign language interpreter. Outside of the office, Sheila enjoys white-water rafting, dancing, a good book, and traveling any chance she gets. Any Questions? Medical Management Managed Health Care/Review, Preadmission/Admission Certification, or Individual Benefits Management and Case Management n n n Voice mail available after office hours and on holidays and weekends Blue Cross of Idaho Help Desk Electronic Billing Errors, Error and Acceptance Reports n 8 a.m. 5 p.m. MT (Monday Friday), n 888-BCI-EDIA, or Provider Contact Center for Commercial and Medicare Advantage Benefits, Coverage and Authorization n 8 a.m. 5 p.m. MT (Monday, Tuesday, Thursday, Friday) 8:30 a.m. 5 p.m. MT (Wednesday) n Commercial: or n Medicare Advantage: or Post-service claim questions log onto our secure website at bcidaho.com and select Contact Us. External Provider Relations Questions regarding website applications such as electronic billing, eligibility, claims, authorizations, internet services or requests for FREE on-site training n or Ext. 8309: Jamie Hunihan Treasure Valley West Ext. 8307: Kathy Brock, CPC-P North Idaho, WA, OR & MT Ext. 8308: Diane Mortensen, CPC South, Southcentral Idaho, NV Ext. 7032: Angeal McCormick Eastern Idaho, UT & NV 2014 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association 9