BlueCare/TennCareSelect. Improving health care for TennCare members
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- Ariel Reed
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1 Improving health care for TennCare members
2 Obtain member eligibility by: Using BlueAccess, the secure area of vshptn.com* and bcbst.com Calling Provider Service - BlueCare TennCareSelect Calling Family Assistance Service Center* Faxing Eligibility Form Accessing the State s online eligibility system at Retroactive Eligibility *For TennCare members only
3 Access just a phone call or mouse click away Answers to administrative issues, claims status, eligibility or prior authorization information Call Provider Service - BlueCare TennCareSelect Call Utilization Management - BlueCare TennCareSelect Log on to BlueAccess on vshptn.com or bcbst.com
4 Disclosure of Ownership and Control Interest Statement What is it and why is it important? What happens if the form is not completed and returned? What sections of the form are required to be completed? Who should sign the form? Obtain a copy of the form by: - Calling Monday through Friday 8 a.m. to 5 p.m., ET and speak Network Contracting - Visiting the BlueCare/TennCareSelect section on the Provider page of the company Web sites, vshptn.com and bcbst.com.
5 Tennessee Medicaid Number Required when rendering care to TennCare members Claims deny with WMN Need State Medicaid Number Obtain a Tennessee Medicaid number by: - Calling Medicaid/TennCare Provider Enrollment Unit at Visiting the Provider page of the company Web sites, vshptn.com or bcbst.com - Visiting the Bureau of TennCare Web site, Submit Tennessee Medicaid number by contacting your local Network Manager or mail to: BlueCross BlueShield of Tennessee Provider Management CH4.2 1 Cameron Hill Circle Chattanooga, TN 37402
6 Medical Prior Authorization is required for: All non-covered, investigational or cosmetic procedures or services All out-of-network services (hospital and professional) Transplants and transplant evaluations Certain Specialty Pharmacy medications Chiropractic services (lumbar, sacral and pelvic) Medically Necessary for children under the age of 21 years DME >$500 for purchase or rental (where allowed amount of the rental equipment would be >$500 if purchased) DME repairs >$500 All Home Health Services and Private Duty Nursing All inpatient admissions (in network) All outpatient therapies (21 years and older) Orthotics and Prosthetics >$200 All bariatric surgeries All hysterectomies All new requests for wheelchairs and accessories regardless of purchase or rental price Hospice-inpatient and outpatient* *This service requires Notification. Global OB* SNF-Skilled Nursing Facility All food supplements and substitutes including formulas taken by mouth for adults 21 years of age and older The following outpatient services: Arthroscopy Endoscopy Laparoscopic Cholecystectomy All services performed by a plastic specialist, including, but not limited to: Abdominoplasty/Panneculectomy Belpharoplasty Breast reduction Gynecomastia Reconstructive repair Pectus Excavatum Reconstructive breast Vein ligation High-technology radiology (CT, MRI, MRA, PET)
7 Primary Care Provider (PCP) Changes Initial PCP assignment PCP lock-in Fax back form Member accept criteria
8 Abortion, Sterilization, Hysterectomy (ASH) Multiple requests for medical records Length of time to review Anesthesia claim denials New ASH fax number:
9 TennCareSelect still exists State s self-insured Health Maintenance Organization Administered by Volunteer State Health Plan Serves as backup program Has same benefits as other Managed Care Organizations Enrollees cannot choose TennCareSelect Behavioral health
10 When other insurance is involved File claim to BlueCare/TennCareSelect with the corresponding remittance advice from commercial carrier File claims within 120 days from date of primary insurer s remittance advice TennCare is always the payer of last resort except for: - Child support enforcement - Crippled children/children services - TENNderCare services - Prenatal or preventive pediatric care
11 Behavioral Health Integration Volunteer State Health Plan (VSHP) administers behavioral health care services to BlueCare members only Inpatient and higher level of care requires prior authorization Submit requests telephonically by mail or via Web site, Call , Monday through Friday, 8 a.m. to 6 p.m., (ET), or mail request to: BlueCare Notification/Prior Authorization P.O. Box Chattanooga, TN File behavioral health claims to BlueCare Effective Sept. 1, 2009, TennCareSelect and SelectKids behavioral health services will be coordinated through VSHP
12 Global and Category II Procedure Code Billing Practitioners are urged to: Submit prenatal care visits that occur within the first trimester or within 42 days of enrollment with VSHP Submit Category II codes (0500F, 0501F, 0502F) Schedule member postpartum care visit to occur between 21 and 56 days after delivery Submit Category II code (0503F) Notify VSHP within 24 hours of a missed appointment Notify VSHP s CaringStart Maternity team at when pregnancy is diagnosed Global and Category II Codes Frequently Asked Questions available on company Web sites, vshptn.com or bcbst.com
13 Care Management Program Offers quality and cost-effective coordination of care Provided at no extra cost All BlueCare and TennCareSelect members are eligible Call , Monday through Friday, 8 a.m. to 6 p.m., (ET) for Case Management Services
14 CareSmart Disease Management Programs Developed to assist members with chronic conditions Consists of support from nurses and other health care staff, educational materials and resources and individual or group educational sessions Member enrollment is voluntary, but encouraged To enroll members call or use the Program Referral Form located in the VSHP Provider Administration Manual
15 Questions? BlueCare/TennCareSelect Ask now Call Provider Service: - BlueCare TennCareSelect
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