11/2/2017. Blue Cross Blue Shield of Michigan and Blue Care Network

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1 Blue Cross Blue Shield of Michigan and Blue Care Network Michigan Medical Group Management Association Third Party Payer Day November 10, 2017 Heather Peterson, Provider Relations Consultant Agenda Physician Assistant Enrollment Project Provider Enrollment Self Service Tool Provider Inquiry PARS When do you need a Global Referral for BCN? How to find what needs an authorization evicore authorizations Provider Resources RC Claim Assist Tool 2 Provider enrollment Physician assistant project All physician assistants need to enroll or re-enroll. Enrollment begins Oct. 1, Forms and practitioner agreements are available online, at bcbsm.com/providers. Click Join Our Network. Current reimbursement arrangements are terminated for dates of service on or after Jan. 31, See articles in The Record (August and October 2017) and Sept./Oct. BCN Provider News. 3 1

2 PAs must re-enroll with Blue Cross and BCN Go to bcbsm.com/providers Enrollment and Changes Provider Enrollment Physicians and Professionals Change an existing provider Physician Assistant 4 Provider enrollment Self-service tool Use the online self-service tool to submit group-level changes electronically: - Allows changes at the group level only - Access through Provider Secured Services Register for Provider Secured Services access using Addendum G. Links to tutorials can be found at bcbsm.com/providers/help/faqs/enrollmentfaqs/training-tools.html The paper Group Change Form will be discontinued. 5 Transactions still requiring paper forms Provider type Transactions requiring paper forms Facility providers All Professional groups and allied providers Individual practitioners Enroll new groups and allied providers Change National Provider Identifier Re-add practitioners to the same group from which the practitioner was disaffiliated Enroll new as a solo practitioner (not in a group) Change Type 1 NPI Change EIN/Tax ID number or tax name Add or remove network participation as a solo practitioner (not in a group) Change BCN primary care physician status as a solo practitioner (not in a group) Add or remove individual practice locations as a solo practitioner (not in a group) Change a remit or mailing address as a solo practitioner (not in a group) Terminate a practitioner as a solo practitioner (not in a group) Note: All other changes should be submitted using the Council for Affordable Quality Healthcare s Universal Provider Datasource, including changes in: Name Degree Social Security number Primary address Specialty and board certification 6 2

3 Provider Automated Response System PARS is the automated Blue Cross and BCN interactive phone system. You can use it to check benefits and eligibility. There are also new PARS features (effective July 14, 2017): - Find the remaining number of visits or days in a benefit period - Check claim status and payment and rejection details - Get information on a check - Get information about member liability 7 Provider Automated Response System When calling PARS, you are asked to choose one of these options: - Benefits and eligibility - Claims If you choose "benefits and eligibility," you ll continue to receive current information for your patient. If you choose "claims," you ll receive claims information, including: - Status of a claim along with payment and rejection details - Information about a check - Member liability 8 Provider Automated Response System When choosing claims PARS will ask if you re checking the status of your claim. If you have received a Remittance Advice for your claim, but need additional assistance, answer No. This option will allow you to speak to a Representative. If you have submitted a claim, but haven t received a Remittance Advice, answer Yes. 9 3

4 BCN referrals and authorizations Who is responsible for submitting referrals? PCPs and specialists If specialists are ordering tests or procedures that require authorizations, their offices should request authorizations from BCN. 10 BCN referrals and authorizations General guidelines For BCN HMO members living in the Mid, West or Upper Peninsula region, no global referral is required as long as the contracted specialist is located in one of those regions. For BCN HMO members living in the East (Green) or Southeast (Orange) region, a referral is required. 11 When do you need a global referral for BCN? BCN Regional Referral Differences for Global Referrals Primary care physician regions based on the location of their Medical Care Group - MidMichigan Medical Center Alpena PCP (MidMichigan PHO Midland) - Tawas St. Joseph Medical Center (St. Mary s PHO Saginaw) How to find a primary doctor's Medical Care Group - Locate primary doctor on web-denis - Use Find a Doctor to identify Medical Care Group 12 4

5 Accessing e-referral 13 e-referral home page detail See the e-referral User Guide for e-referral home page specifics in the Navigating the Dashboard section. 14 Which services need authorization? How to find which services require authorization For Blue Cross PPO: The requirements are contract specific. Look up the member's benefits using Benefit Explainer. Look in the Blue Cross provider manuals: - Radiology management procedure codes - Preapproval of services Drugs covered under the medical benefit: - Use the link in web-denis to access NovoLogix. - You can also visit ereferrals.bcbsm.com and click Blue Cross. Then click to open the Medical Benefit Drugs Pharmacy page. 15 5

6 Which services need authorization? How to find which services require authorization For Blue Cross Medicare Plus Blue: On the public ereferrals.bcbsm.com website, click Blue Cross and then click to open a specific page: - Authorization Requirements & Criteria page - evicore-managed Procedures page - Medical Benefit Drugs Pharmacy page 16 Which services need authorization? 1 Visit ereferrals.bcbsm.com. 2 Click Blue Cross. 3 Click to open a specific page. 17 Which services need authorization? How to find which services require authorization For BCN HMO (commercial) and BCN Advantage: On the public ereferrals.bcbsm.com website, click BCN and then click to open a specific page: - Clinical Review & Criteria Charts page - evicore-managed Procedures page - Medical Benefit Drugs Pharmacy page 18 6

7 Which services need authorization? 1 Visit ereferrals.bcbsm.com. 2 Click BCN. 3 Click to open a specific page. 19 evicore Providers must obtain clinical review from evicore healthcare (formerly CareCore National) All BCN-participating freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices are required to use. As of July 31, 2017, Medicare Advantage PPO also utilizes evicore for the following: Joint replacement (hip, knee, shoulder) Hammertoe surgery Nasal sinus endoscopy Endovascular intervention, peripheral artery Transcatheter placement of intravascular stents Vascular embolization or occlusion (TACE, RFA or UAE) Insertion or replacement of cranial neurostimulator pulse generator Implantation of devices for intrathecal or epidural drug infusions Percutaneous implantation of neurostimulators (epidural, sacral nerve or gastric) Requests for review must be submitted by visiting evicore.com or by calling After clicking on BCN, go to evicore-managed Procedures 21 7

8 Access evicore FAQs, authorization and clinical review criteria 22 Authorization Requirements & Criteria 23 Upcoming authorization changes for Blue Cross Commercial Preauthorization program launches in January Category: Commercial PPO Beginning Jan. 1, 2018, our fully insured and IBU commercial Blue Cross PPO plans will require pre-authorizations for the following programs: - Interventional pain management - Radiation therapy (oncology) services - Inpatient and outpatient lumbar spinal fusion surgery These programs will be administered by evicore healthcare, a national specialty benefits management company that focuses on quality, cost and use of health care services. For more information, see the October Record article titled Preauthorization program for commercial PPO plans coming in January. Look for more detailed information about the programs in future web-denis alerts and Record articles. 24 8

9 Resources for providers 1 Visit bcbsm.com/providers. 2 Log in to Provider Secured Services. 3 Click web DENIS. From this page, you can access: Blue Cross resources BCN resources Provider manuals evicore healthcare authorization for Blue Cross Medicare Plus Blue SM 25 Resources for providers Click BCBSM Provider Publications and Resources, to access Blue Cross PPO (commercial) information. 26 Resources for providers Click BCN Provider Publications and Resources to access BCN HMO SM (commercial) and BCN Advantage SM information. 27 9

10 Resources for providers Click Provider Manuals. 28 What is RC Claim Assist? RC Claim Assist, a web-based, easy-to-use resource for correctly billing National Drug Code units for medical drug HCPCS/CPT codes Blue Cross Blue Shield of Michigan and Blue Care Network have collaborated with RJ Health Systems to offer a comprehensive resource to assist you and our provider network with billing medical drug claims. 29 RC Claim Assist benefits A comprehensive crosswalk of HCPCS/CPT drug codes, product names and NDCs Complete drug information on package-size billable units and reference pricing Allows for immediate claim check prior to billing for services 30 10

11 Do s and don ts of RC Claim Assist DO As a general reference only, along with other sources such as an applicable fee schedule DO To review data within the tool, which are real time and not date-of-service specific DO NOT USE FOR: QUOTING BENEFITS MEDICAL POLICY REVIEW 31 e2 Accessing the RC Claim Assist Visit ereferrals.bcbsm.com and click BCN at the top. Under the BCN Authorizations/Referrals section, click Medical Benefit Drugs Pharmacy. Under the heading Billing/pricing information for BCN commercial members only, click RC Claim Assist log-in. NOTE: FIRST TIME USERS WILL HAVE TO LOG IN AND REGISTER 32 Accessing the RC Claim Assist Visit ereferrals.bcbsm.com and click BCN at the top. 2. Under the BCN Authorizations/Referrals section, click Medical Benefit Drugs Pharmacy. 11

12 Slide 32 e2 Is it correct to say that if the providers has an Ereferral log in they can use this as the log in for RC Claim Assist? e123665, 9/25/2017

13 Accessing the RC Claim Assist 3. Click RC Claim Assist log-in. 34 First-time user of RC Claim Assist As a first time user you will have to Visit website Note: Please have your NPI available for log-in 35 RC Claim Assist 36 12

14 RC Claim Assist 37 Let s go live 38 Contacts or concerns How to submit National Drug Codes on claims: Refer to The Record, February 2015 article The data on RC Claim Assist: send an to info@rjhealthsystems.com Billing or claims: Contact Provider Inquiry A claim that is contractual or complex in nature: Contact your provider consultant 39 13

15 Top take a-ways Physician Assistants need to re-enroll for Blue Cross and Blue Care Network All Groups need to enroll for Provider Self Service Tool Navigating the PARS system When are Global referrals required Locating medical and evicore referral requirements on-line Locating BCBSM and BCN provider manual on-line Accessing and using the RC Claim Assist Tool Heather Peterson West Michigan Provider Relations Consultant Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 14