BCBSNC Best Practices Thank you for attending today! We value your commitment of caring for our members your patients and our shared goals for their improved health An independent licensee of the Blue Cross and Blue Shield Association
Topics for today Self service tools available Member s copayments Medical records Credentialing Claims basics Managing care Diagnostic imaging management program Provider demographics 2
Add title for transition slide Self service tools available on your schedule not ours 3
Online resources bcbsnc.com/providers/ Blue Book SM Medical policies Important news Prior review pages Specialty pharmacy Member formularies Newsletters 4
Blue esm In real-time and from the convenience of your computer without any phone time delay Blue e SM offers easy access to many self help Internet based functions, which include: Eligibility inquiry Claim status inquiry UB-04 & CMS-1500 claim entry. Also, corrected claims entry Batch 837 transaction claim denial listings Remittance inquiry (EOP/NOP) detail for all lines of business Admission notification and inquiry (Hospitals) Clear Claim Connection (C3) explains bundling logic Diagnostic imaging prior approval Manage account 5
Clear Claims ConnectionTM (C-3) Application to help providers understand our bundling logic Links to medical policy for further clarification Is not a guarantee of payment 6
Available through the Blue esm portal Auditing rules for claims processed on the Power MHS system 7
Available through the Blue esm portal Auditing rules for claims processed on the Power MHS system 8
Voice response unit (VRU) 1-800-214-4844 Our voice recognition system offers callers speech recognition vs. slower touchtone functionality. The system allows callers to enter information upfront for as many members as callers need information. Calls are routed to the representative with the shortest. hold time. Representatives are specially trained for each line of business. 9
Add title for transition slide Member s copayments 10
Copayments Members with a coverage plan that includes office visit copayments are responsible for the copayment at the time service is received. You should collect the copayment amount listed on the member s BCBSNC ID card when: A charge for an office visit is made using an evaluation and management (E/M) code Surgery is performed in the office A second surgical opinion or consultation service is provided The patient is seen by a physician, physician s assistant, clinical nurse practitioner, nurse midwife, physical therapist, occupational therapist or speech therapist 11
Copayments Copayments should not be collected when there is not an E/M service code for an office visit being charged (e.g., when a member comes in to get an allergy injection, lab service only or a second surgical opinion, consultation or surgery is performed, in addition to the office visit). Copayments are not required when members are receiving chemotherapy, radiation therapy or dialysis performed in the office and are not being billed for an E/M service, or when services are provided in a hospital setting. 12
Add title for transition slide Medical records 13
Medical records When medical records are needed to complete the processing of a claim, we will notify the provider whom records are needed from, in writing, using a BCBSNC medical records request form: The medical records request form contains a routing code that allows the records to be scanned and sent directly to the individual in claims review, who is waiting to complete the processing of the pending claim(s). When sending medical records, always include the medical record request form, placed as the top sheet, on top of the medical records. 14
Medical records Please only send medical records when you ve received this form 15
Medical records Our mailrooms and front-end scanning staff have detailed processes to expedite scanning of requested medical records. When the medical records request form is not included, we cannot always match the medical records received with the correct member s claim and/or route to the correct business area for processing. 16
Add title for transition slide Credentialing 17
Common pitfalls to avoid when submitting an Initial Credentialing Application Be sure that all education and work history information is supplied in month/year format with an explanation of any and all gaps of 90-days or more. Always complete the Attestation page in its entirety Provide current professional liability insurance, which included the policy face sheet indicating by name all providers covered, liability coverage amounts, policy effective date, policy expiration date and policy number. 18
Common pitfalls Initial Credentialing Application Providers practicing in an Urgent Care facility must submit proof of ACLS and ALS/PALS certification along with the Provider Attestation of Urgent Care Competencies The attestation can be found on the BCBSNC Web site located on the Credentialing Instructions page. When utilizing CAQH be sure that all information is updated and all supporting documents are current in CAQH Visit our Web site at bcbsnc.com to review instructions and requirements, to read detailed information pertaining to provider specialty types and to obtain necessary forms 19
Add title for transition slide Claims basics 20
Claims filing For fastest claims processing, file electronically! Submit all claims within 180 days. Do not submit medical records unless they have been requested by BCBSNC. If BCBSNC is secondary and you re sending to us the primary payor explanation of payment (EOP) with your paper claim, do not paste, tape or staple the explanation of payment to the claim form. 21
Claims filing Always verify the patient s eligibility via the HIPAA 270 inquiry, Blue e SM, RealMed or the Provider Blue Line SM. Always file claims with the correct member ID number, including the alpha prefix and member suffix, whenever applicable. Use the appropriate provider/group NPI(s) that match the NPI(s) that is/are registered with BCBSNC for your health care business. 22
Claims filing BCBSNC cannot correct claims when incorrect information is submitted. Claims will be mailed back. Claims filing guidelines stated in the Blue Book SM Provider Manual must be followed. In the absence of specific BCBSNC requirement regarding coding, providers are required to follow the general coding guidelines that are published by the issuer of the coding methodology being utilized. For example, for CPT code filings, you must file the most accurate CPT codes specific to the service(s) rendered. 23
Claims filing with unlisted codes Per CPT/HCPCS coding guidelines, all unlisted codes require the submission of pertinent records, such as the operative report, detailed description of the service in question, etc to support the use of the unlisted code. For unlisted drugs, such as codes J3490, J3590, J9999, we require the NDC number and the name and dosage of the drug provided. For unlisted DME codes E1399 and K0108 remember to include the description of the DME item, and the manufacturer s invoice. If there is a valid CPT or HCPCS code, then do not submit a unlisted code. 24
Top reasons that can delay a claim Missing or invalid NPI (national provider identifiers [for individual and/or group]) Missing, invalid or incomplete member ID (always include the complete member ID including applicable alpha prefixes and numeric suffixes as they appear on the member s current ID card) Missing patient s date of birth Missing or incorrect number of units Missing or invalid place-ofservice code (filing one digit code instead of a two-digit code) Missing onset date of symptoms Missing or incomplete specific diagnosis Missing primary payor s EOB if BCBSNC is secondary Missing admission and discharge dates for inpatient claims 25
Claim form mail-backs Claims are mailed back because information needed to process the claim is missing, incomplete or invalid. In general, claims that are mailed back have not been entered into our claims processing systems. A new claim will be needed, submit a new claim not a corrected claim. Return to Sender 26
Correcting claims All services and/or charges must be submitted on the corrected claim: Claim forms must indicate changes without erasing or marking out information that was originally submitted. The resubmitted paper claim must be clearly marked with the title Corrected Claim. Do not Corrected Claim Corrected Claim Stamp at top upper right corner Corrected Claim Remember that if a a claim is mailed back to you it is no longer in our system. When re-filing for the services, the claim is considered a new claim and not a corrected claim. 27
Correcting claims Bill Type The bill type identifies a corrected UB-04 claim Reminder: Corrected claims can now be filed electronically for both Professional and Institutional services. Visit Blue e SM for more details. 28
Automatic crossover for all Medicare claims All Blue Plans crossover Medicare claims for services covered under Medigap and Medicare Supplemental products, resulting in automatic claims submission of Medicare claims to the Blue secondary payor. Automatic crossover applies to both local BCBSNC claims and IPP BlueCard claims. The Medicare crossover process applies to all provider types, including: hospitals and facilities, professional providers, ancillary providers, federally qualified health centers, rural health clinics and comprehensive outpatient rehabilitation facilities. 29
Crossover verification When you receive the remittance advice from the Medicare intermediary, look to see if the claim has been automatically forwarded (crossed over) to BCBSNC or another Blue Plan: If the remittance indicates that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to BCBSNC. If the remittance indicates that the claim was not crossed over, submit the claim to BCBSNC with the Medicare remittance information. 30
Crossover payment Claims submitted to the Medicare intermediary will be crossed over to BCBSNC or the out-of-state Blue Plan, only after they have been processed by the Medicare intermediary. This process may take up to 14 business days. This means that the Medicare intermediary will release the claim to BCBSNC or the out-of-state Blue Plan for processing at about the same time you receive the Medicare remittance advice. As a result, it may take an additional 14 to 30 business days for you to receive payment from BCBSNC or the out-of-state Blue Plan. 31
Crossover missing? If you ve submitted a claim to the Medicare intermediary/ carrier and have not received a response to your initial claim submission, do not automatically submit another claim. Instead: Review the automated resubmission cycle on your claim system Wait 30 days Check claims status before resubmitting Sending another claim, or having your billing agency resubmit claims automatically, actually slows down the claim payment process and can create confusion for the member. 32
Add title for transition slide Managing care 33
Medical-necessity decisions BCBSNC uses two sets of criteria and guidelines to make medical necessity decisions: the Milliman Care Guidelines and BCBSNC corporate medical policy. Most of our licensed nurses use Milliman Care Guidelines to authorize coverage for inpatient services and for lengthof-stay extensions. They also use the Milliman Care Guidelines for home care and rehabilitation services. Our corporate medical policy applies more to services that require prior approval. Medical Resource Management 1-800-672-7897, ext. 57078. 34
Health coaches Health coaches are available to discuss the health care management process and the authorization of services for your patients. You can obtain certification, request discharge services, and get information regarding a request by calling 1-800- 672-7897 Monday Friday, 8 a.m. 5 p.m., EST. When calling after hours for discharge services, leave a detailed message 35
Health coaches If you are contacting health coaching to request prior approval, you may request by fax or use our online request form, both available on the BCBSNC Web site. When faxing, please use one of the following numbers, 24 hours a day, 7 days a week: State PPO: 1-866-225-5258 Region 1 Asheville/Charlotte: 1-800-459-1410 Region 2 Raleigh/Chapel Hill/Greenville: 1-800-571-7942 (includes outof-state requests) Region 3 Durham/Greensboro/Winston Salem/Wilmington: 1-800-672-6587 Pharmacy: 1-800-795-9403 Discharge Services: 1-800-228-0838 36
Prior review Reviews are done to confirm the following: Member eligibility Benefit coverage Compliance with BCBSNC corporate medical policy regarding medical necessity Appropriateness of setting Requirements for utilization of in-network and out-of-network facilities and professionals Identification of comorbidities and other problems requiring specific discharge needs Identification of circumstances that may indicate a referral to concurrent review, discharge services, case management or the Member Health Partnerships SM program 37
Prior review The Prior Review list is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter. BCBSNC updates the list in advance to allow 90 days notice that a code has been added for review. 38
Prior review More information about which services require prior review, instructions on how to request prior review and the prior review list, are available on our Web site at bcbsnc.com/providers/ppa/. Admissions and Diagnostic imaging Prescription drugs Other services and private duty nursing procedures Including skilled nursing facility admissions and private duty nursing service. Learn more or submit a request >> Including CT/CTA,PET and MRI/MRA scans and nuclear cardiology studies. Learn more or submit a request >> Including cox 2 inhibitors, antifungals, weight loss and allergy drugs. Learn more or submit a request >> Such as home health care services, durable medical equipment and mental health. Learn more or submit a request >> 39
Prior review approval Providers have two Web based options for submitting requests for prior review approval. If contacting BCBSNC after hours to request prior review approval, you need only provide your important contact information. A BCBSNC representative will return your call the next day to collect complete information. Forms are available via the prior plan approval page at bcbsnc.com/providers/ppa/ 40
Add title for transition slide Diagnostic imaging management program 41
Diagnostic imaging management program Prior authorization is required for high-tech diagnostic imaging services when performed in a physician's office, the outpatient department of a hospital, or a freestanding imaging center: CT/CTA scans MRI/MRA scans Nuclear cardiology studies PET scans American Imaging Management (AIM) administers the diagnostic imaging program. 42
Diagnostic imaging management program Ordering physicians must contact AIM to obtain prior authorization before scheduling an imaging exam for outpatient diagnostic, non-emergency services. Servicing providers (hospitals and freestanding imaging centers) should confirm that prior authorization was issued prior to performing the service. Only ordering physicians can obtain prior plan approval. Hospitals and freestanding imaging centers that perform the imaging services cannot obtain prior plan approval. Servicing providers have up to 72 hours after the date of service to add an additional CPT code for a contiguousbody part (e.g. adding abdomen to pelvis) to an existing AIM authorization 43
Diagnostic imaging management program Shared commitments Ordering provider s relationships with imaging centers and outpatient facilities where they refer Imaging centers and outpatient facilities relationships with their reading providers and vice versa Each have a vital role in arranging and delivering patient care and ensuring that authorizations are obtained Reading provider Ordering provider Imaging center or outpatient facility 44
Diagnostic imaging management program Locations Included places of service: Freestanding imaging centers Hospital outpatient In-office use of physicianowned equipment Not included places of service: Inpatient Emergency room Ambulatory surgical center Urgent care center 45
Diagnostic imaging management program Services Included outpatient imaging services: CT, CTA Nuclear cardiology (e.g. SPECT scans) PET scans Magnetic resonance imaging (MRI / MRA / MRS) 46
Diagnostic imaging management program Making a request? Request prior plan approval for diagnostic imaging procedures: Online: ProviderPortal SM using Blue e SM By fax: Prior plan approval fax request form By phone: American Imaging Management 1 866 455 8414 Monday Friday, 8 a.m. 5 p.m., Eastern Time 47
Available through the Blue esm portal 48
Diagnostic imaging management program Oncologic PET Scan form Form available at: bcbsnc.com/providers 49
Diagnostic imaging management program 12/01/08 Claims processing change for facilities Prior to 12/01/08, outpatient claims from facility providers were denied if they contained a DIM service and PA was not obtained. Under the revised process, outpatient DIM claims processed on or after December 1, 2008 are compared with the DIM PA list to see if any CPT on the claim requires PA; if so, the DIM claim type is assigned to that claim line rather than to the entire claim and the DIM CPT code line will be denied. 50
Want to find out more? Diagnostic imaging resources on the Web More information get answers to your questions about this program by reviewing the frequently asked questions. Medical policy information review guidelines governing the use of diagnostic imaging procedures by reviewing our medical policies. Training materials @ bcbsnc.com/providers/imaging/ Program overview Ordering Provider Quick Reference Guide Servicing Provider Quick Reference Guide AIM Provider Portal Quick Reference Guide Troubleshooting Guide for Common Set up Issues Provider Training Presentation on BCBSNC s Diagnostic Imaging program (with audio feature) 51
Add title for transition slide About you provider demographics 52
BCBSNC needs your correct information BCBSNC routinely updates the online provider directory with addresses, phone numbers and current lists of all providers at a participating facility or practice, so that our members can quickly locate health care providers and schedule appointments. If you think that your information may be in need of updating, please let us know by contacting your regional Network Management representative or complete and return a provider demographic form that can be found on the providers page on our Web site at bcbsnc.com/providers/. 53
Contract notices Some health care business maintain a separate mailing location and/or designate an individual to receive mailings pertaining to contract notices. If your business requires special handling of notices, please let us know by sending your information to: BCBSNC Network Management Operations P.O. Box 2291 Durham, NC 27702-2291 When sending, please send in writing using your businesses corporate letterhead and have signed by your businesses owner, CFO, or another having contract signing authority. 54
Add title for transition slide Your questions? Thank you 55