PROVIDER RELATIONS SEMINAR OCTOBER 7, 2009. SEMINAR AGENDA. Welcome – Jeanne Wisnewski, Director Provider Relations Blue Health Plan Updates – Jill Jenkins 5010/ICD 10 Updates – Dawn Reece Medical Director Updates – Thomas A. Curry, M.D. EDI Tips – Rebecca Krasson
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BCNEPA UB-92 Claim System Shutdown
Are there precertification requirements?
P.O. Box 890179
Camp Hill, Pa 17089-0179
Highmark CMS-1500 Paper Claim Form
Personal Choice Claims
P.O. Box 69352
Harrisburg, PA 17106-9352
Medicare Advantage PPO Network Sharing
Contracted BCNEPA/HMBS Medicare Advantage PPO Providers
P.O. Box 890170
Camp Hill, Pa 17089-0170
P.O. Box 81460
Rochester Hills, MI 48308-1460
Non-Contracted BCNEPA/HBS Medicare Advantage PPO Providers
Submit the claims to your local Blue Plan as you do for all out-of-area Blue members.
P.O. Box 890179
Camp Hill, PA 17089-0179
Act 62 required private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorders (ASD).
Medical Policy and Information
Is available on BCNEPA’s Provider Center at www.bcnepa.com or via the link on Navinet.
If you do not have access to the Internet, please contact your Provider Relations Consultant for a hard copy of the medical policy.
Check your BCNEPA Provider Bulletins for updates.
Another resource is the DPW’s site
The Frequently Asked Question and Answers section maybe helpful.
Presenter: Dawn Reece
The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner.
Analyze Your Subparts !!
The NPI used to identify the Rendering Provider or the Service Location must be external to the entity identified as the Billing Provider (for example; reference lab).
It is not permissible to report an organization health care provider’s NPI as the Rendering Provider or the Service Location if the Rendering Provider or Service Location is a subpart of the Billing Provider.
Analyze Provider Data !!
ICD-9 Will No Longer Be Used As Of October 1, 2013
MEDICAL DIRECTOR UPDATESPresenter: Thomas A. Curry, M.D. Medical Director Network Management Provider AdvocacyTransparency Initiative at BCNEPA
The provision of clinical quality and cost information to health professionals and health plan members in a manner that assists in the healthcare decision making and helps to raise the level of quality care.
To provide clinical measures and subsequently cost measures, with a peer group comparison that is:
Important aspects to be reviewed by professional community:
Hospitals: Information based on PHC4 and CMS data is already available as ‘Hospital Advisor’
Professional: Limited information already in place with demographic data under ‘Find a Physician’
QC = Patient
All of these codes can be found on the
Washington Publishing Company website:
EDI rejections are listed in the 2007 BCNEPA Provider Bulletins for January, February, May, September, October and November.
Effective June 12, 2009, BCNEPA and NaviNet have redesigned the
Eligibility and Benefits Inquiry screens to make pertinent information
more easily accessible. Here are some highlights:
Eligibility and Benefits Inquiry
BlueExchange Eligibility and Benefits Inquiry
The BlueExchange Eligibility and Benefits Inquiry screen has also been redesigned. Here are some highlights:
Other updates effective June 12, 2009 include:
PRIOR AUTHORIZATION SUBMISSION TRANSACTION
UB 04 CLAIM ENTRY AND SUBMISSION
(Note: Providers who have multiple offices/locations must ensure that NaviNet access is granted to each office/location that may require its functionality. Only the provider’s NaviNet Security Officer has the capability to grant “user” access under each provider’s NaviNet account. Further information on granting NaviNet “user” access is available under the NaviNet Customer Support link once signed into NaviNet.)
Elimination of Hardcopy Provider Bulletin
To coincide with our dedication to increasing our BCNEPA NaviNet capabilities and our initiative to transition providers to utilize NaviNet as the preferred source of BCNEPA information, BCNEPA will be eliminating the mailing of the hardcopy Provider Bulletin for NaviNet enabled providers.
Beginning January 2010, NaviNet-enabled providers will no longer receive a hardcopy version of the BCNEPA Provider Bulletin via mail. The BCNEPA Provider Bulletin will remain posted and can be reviewed/printed from the BCNEPA Provider Center website that can be accessed through a provider’s NaviNet account.
BCNEPA will post a Blue Alert during the 1st week of each month on NaviNet when a new edition of the Provider Bulletin is available for display.