provider relations seminar october 7 2009 n.
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  2. 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 • NaviNet/NPO Initiative – Cheryl Hashagen

  3. BLUE HEALTH PLAN UPDATESPresenter: Jill Jenkins

  4. BCNEPA UPDATES BCNEPA UB-92 Claim System Shutdown • In January 2008 BCNEPA converted its internal UB-92 claims processing system to another claims processing platform. • Products affected by the change were: • Blue Cross (non-FPLIC) • BlueCard • FEP claims • Affected claims with dates of service prior to January 1, 2008. • This did not apply to First Priority Health or First Priority Life Insurance Company claims.

  5. BCNEPA UPDATES • Due to the UB-92 Claim System Shutdown, BCNEPA is requesting providers submit all claims and claim adjustments by January 31, 2010 for dates of service prior to January 1, 2008. • Timely filing guidelines will apply to both claim and claim adjustment submissions. • Eligible claims or claim adjustments received after the system shutdown date will be handled administratively and will require additional time for completion.

  6. FIRST PRIORITY HEALTH (FPH) UPDATES • YZH is the alpha prefix for all First Priority Health (FPH) products • Provider Services – 1-800-822-8752 • Member Services – 1-800-822-8753

  7. FPH AUTHORIZATION UPDATES • As of 7/1/09, FPH participating hospitals are no longer required to submit FPH Maternity Admission fax sheets • All newborn admissions not covered under the mother’s insurance and detained babies must continue to be phoned into FPH’s Utilization Management Area. • Effective 8/1/09, FPH no longer requires prior authorization for behavioral health care outpatient services for participating providers. • Prior authorization is still needed for non-participating providers. • Prior authorization is still needed for inpatient and partial hospitalization services.

  8. FPH UPDATES • 9/1/09 Geisinger Health System Hospital and Physicians became participating with FPH • Geisinger Medical Center in Danville is not participating with FPH. • The Outpatient Laboratory and Radiology Program remains in effect. • If a member has a Primary Care Physician (PCP) office located in Luzerne or Lackawanna County, they must continue to have outpatient laboratory services performed at one of the Pennant Laboratories’ designated outpatient laboratory sites. • If a member has a PCP office located in Luzerne County, they must continue to have outpatient radiology services performed at Wilkes-Barre General Hospital, the Saxton Pavilion in Edwardsville, etc. PCP offices located in either Hazleton or Berwick are respectively excluded.

  9. FPH CLAIM SUBMISSION • Please remember to include your FPH legacy number when submitting a paper claim to FPH. • Your FPH legacy number must contain six digits (leading zeros are required) • NUCC-1500 form – Box 19 • UB-04 form – Locator 57 • Paper claims submitted without the FPH legacy number will deny with one of the following: • XBD “Provider/Tax ID is invalid or missing” • XHN “Provider legacy # not reported in field 19. This # is required.” (NUCC-1500) • XHO “Provider legacy # not reported in field 57. This # is required.” (UB-04) • If your claim denied for one of the above reasons, the claim must be submitted as a new claim.

  10. FIRST PRIORITY LIFE INSURANCE COMPANY (FPLIC) • BCNEPA’s medical policy can be found in two (2) locations. • Providers should primarily reference Blue Cross of NEPA’s website at for FPLIC medical policy. • In situations where a medical policy is not on Blue Cross of NEPA’s website, providers should defer to Highmark Blue Shield’s website at for FPLIC medical policy. • To view either BCNEPA or HBS medical policies, visit: • BCNEPA medical policies • HBS medical policies

  11. FPLIC PRODUCT EXPANSION • BlueCare Direct Select • PPO individual product • QFD alpha prefix • BlueCare Direct Essentials • PPO individual product • QFD alpha prefix • BlueCare EPO • EPO product • QFI or QFO alpha prefix

  12. WHAT IS AN EPO? • Exclusive Provider Organization • A form of PPO in which patients must visit with a caregiver that is on the EPO’s panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office or hospital visit.

  13. BLUECARE EPO • A group product BCNEPA began offering in January 2009 • Offered in our 13-county service area • Members may reside and/or work either inside or outside of our 13-county region • BlueCare EPO prefixes: • QFIalpha prefix indicates a member resides or works inside our 13-county service area • QFO alpha prefix indicates a member resides or works outside our 13-county service area

  14. BLUECARE EPOFREQUENTLY ASKED QUESTIONS • Am I an EPO participating provider? • If you currently contract with FPLIC PPO or have a direct contract with FPLIC EPO, you are part of the FPLIC EPO network. • How will I be reimbursed? • The FPLIC EPO reimbursement rates will be your then-current FPLIC PPO or your direct contracted EPO rates.

  15. WHAT IS THE DIFFERENCE BETWEEN QFI AND QFO MEMBERS? • QFI is for members who reside or work within BCNEPA’s 13 county service area. • QFI members must seek service from a FPLIC EPO provider in order to obtain the highest level of benefits. • QFI members do not have a benefit for services provided by a non-participating FPLIC EPO provider within BCNEPA’s 13 county service area (with the exception of emergency services). • QFI members have a lower-level benefit available outside of BCNEPA’s 13 county service area if the member receives services from a participating BlueCard PPO Provider.

  16. WHAT IS THE DIFFERENCE BETWEEN QFI AND QFO MEMBERS? • QFO is for members who reside or work outside BCNEPA’s 13 county service area. • A QFO member may seek services from a FPLIC EPO provider. • A QFO member may also see any BlueCard PPO network provider outside of BCNEPA’s 13 county area and still receive the higher-level benefit. Are there precertification requirements? • Yes. • Within BCNEPA’s 13 county area, please refer to the listing of FPLIC EPO diagnosis/procedure codes found in the November 2008 BCNEPA Provider Bulletin. • Providers outside of BCNEPA’s 13 county area (i.e. Lehigh Valley and Berwick) must follow full precertification requirements.

  17. FPLIC EPO CLAIM SUBMISSION • FPLIC EPO providers should file all claims directly with FPLIC. • All paper claims are sent to: Claims P.O. Box 890179 Camp Hill, Pa 17089-0179 • Electronic claims • Facility – business as usual. Please continue to send UB04 electronic claims through your vendor/clearinghouse to BCNEPA/FPLIC as you do today. • Professional/Ancillary – Please refer to the FPLIC Billing Guidelines on page 3 of the June 2008 BCNEPA Provider Bulletin.

  18. HIGHMARK BLUE SHIELD UPDATES Highmark CMS-1500 Paper Claim Form • Only original (red) NUCC-1500 (08/05) claim forms will be accepted. • Do not submit photocopies of claim forms. • Highmark has a target date of January 1, 2010 to accept only original (red) NUCC -1500 (08/05) version.

  19. REMINDER • Highmark Blue Shield does not process (professional provider) Independence Blue Cross (IBC) Personal Choice claims. • BCNEPA/Highmark does not have access to professional provider IBC Personal Choice claim information. • Personal Choice members can be identified by the following prefixes: • ADQ AEK AEV AEW AHJ BMEBYN CDJ CDQ CDZ CQA CQXDAZ DGR DPX DVU EEN EGDETF GCY GEA GMA HAJ HXTINW MGL NFY NLR PCX QCAQCB WCM SDA SEZ SFU SHQSKH SQT WYK TFE TLG TRXUBF UFN UFP UFT UTR

  20. REMINDER (continued) • IBC Personal Choice Professional Claims should be sent to: Personal Choice Claims P.O. Box 69352 Harrisburg, PA 17106-9352 • Electronic Billers must utilize NAIC 54704 • Provider Services for IBC Personal Choice claims • 1-800-ASK-BLUE (800-275-2583)

  21. GENERAL UPDATES Medicare Advantage PPO Network Sharing • Beginning January 1, 2010 all Blue Medicare Advantage PPO Plans will participate in a reciprocal network sharing. • The MA in the suitcase on the member’s card will help you identify these members. • Benefits and eligibility can be verified by calling BlueCard eligibility at 1-800-676-BLUE (2583).

  22. MEDICARE ADVANTAGE PPO NETWORK SHARINGHOW TO SUBMIT CLAIMS Contracted BCNEPA/HMBS Medicare Advantage PPO Providers • Submit all Medicare Advantage PPO claims to BCNEPA/HBS as you currently bill for FreedomBlue members. • Electronic claims are to be submitted directly to Highmark via trading partner agreement with 378 plan code / NAIC # 54771C. • Paper Claims: FreedomBlue P.O. Box 890170 Camp Hill, Pa 17089-0170 • DME, Respiratory Supplies, Orthotics/Prosthetics: DMEnsions Inc P.O. Box 81460 Rochester Hills, MI 48308-1460

  23. MEDICARE ADVANTAGE PPO NETWORK SHARINGHOW TO SUBMIT CLAIMS 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. • Paper Claims Claims P.O. Box 890179 Camp Hill, PA 17089-0179

  24. PENNSYLVANIA’S AUTISM INSURANCE ACT (ACT 62) Act 62 required private health insurance companies to cover the cost of diagnostic assessment and treatment of autism spectrum disorders (ASD). • Coverage information: • Children under the age of 21 • Insured employer groups having 51 or more employees • Customer service can assist in determining if the group has 51+ employees. • Maximum benefit of $36,000 per year • Coverage is subject to copayment, deductible and coinsurance as it would be for other covered medical services and any other general exclusions or limitations. • Once the member reaches $36,000, he/she may be eligible for additional Medical Assistance (MA) program benefits.

  25. PENNSYLVANIA’S AUTISM INSURANCE ACT (ACT 62) • Pharmacy • Prior authorization is required for employer groups that do not have a pharmacy benefit • Prior authorization can be obtained by contacting Express Scripts at 1.877.603.8399. • If a group does have a pharmacy benefit, no prior authorization is required. • Reimbursement • BCNEPA/FPH/FPLIC standard fee schedules and contracted rates apply.

  26. PENNSYLVANIA’S AUTISM INSURANCE ACT (ACT 62) Medical Policy and Information Is available on BCNEPA’s Provider Center at 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.

  27. FEDERAL MENTAL HEALTH PARITY AND EQUITY ACT OF 2008 • The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was signed into law as part of the Federal Emergency Economic Stabilization Act and becomes effective beginning November 1, 2009 upon group renewal. • The legislation requires group health insurers to apply the same mental health and substance abuse benefits, if they are provided, in parity with (or equal to) medical benefits, including: • member cost-sharing – such as deductibles, copayments, out-of-pocket expenses; • treatment limitations – such as the maximum number of outpatient visits, days of coverage, limits on the frequency of treatment; • out-of-network coverage – group plans are required to provide out of network mental health/substance abuse benefits if the group provides out of network medical/surgical benefits. • Please contact customer services to verify benefits and eligibility.


  29. 5010/ICD 10 UPDATES HIPAA 5010 Presenter: Dawn Reece

  30. 5010 GENERAL INFORMATION • 5010 is the next version of HIPAA mandated electronic transactions. • Currently, the industry is using version is 4010a1. • All HIPAA mandated EDI transactions conducted after January 1, 2012 must be in version 5010. • The following are HIPAA mandated EDI transactions: • Professional Claims (837P) • Institutional Claims (837I) • Remittance Advice (835) • Claim Status Inquires & Responses (276/277) • Benefit Inquires & Responses (270/271) • Request for Authorization (278)

  31. HOW IS 5010 DIFFERENT? • NPI Subpart reporting changes. • Clarifies business usage rules for Billing, Rendering, and Service Facility Location provider loops. • Supports ICD-9 and ICD-10 Code Sets. • Added POA “Present on Admission” indicators. • Clarifies COB “Coordination of Benefits”. • Allows for the submission of two Anesthesia Related Surgical Codes. • Clarifies and strengthens Remittance Advice balancing rules. • Additional benefit categories for benefit inquiries.

  32. 5010 BILLING PROVIDER 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.

  33. NPI SUBPART ANALYSIS Analyze Your Subparts !! • Revisit your NPI subpart enumeration strategy. • Analyze how you report NPI subparts for all payers. • Develop one common reporting scheme that satisfies requirements for all your payers. • Consult with all of your payers before making any changes.

  34. RENDERING/SERVICE FACILITY PROVIDER 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.

  35. BILLING/RENDERING/SERVICE FACILITY Analyze Provider Data !! • Review Billing, Rendering, and Service Facility reporting to ensure you are compliant with new usage requirements. • Verify the billing provider address you are using – 5010 requires this address to be a physical street address. Post Office (P.O.) boxes are not allowed.

  36. ICD-10 ICD-9 Will No Longer Be Used As Of October 1, 2013 • The government mandated the usage of ICD-10 DM and ICD-10 CM effective October 1, 2013. • ICD-10 CM replaces the ICD-9 DM code set used for reporting diagnosis and ICD-9 CM code set used for inpatient procedure code reporting.


  38. DIAGNOSIS CODES FOR SPRAINED & STRAINED ANKLES: ICD-9-CM VS. ICD-10-CM • ICD-9 Sprained Ankle has 4 codes • ICD-10 Sprained Ankle has 72 codes.

  39. WHY REPLACE ICD-9 ? • Almost 30 years old • Outdated, obsolete codes • Some categories are running out of space • Evolving healthcare data needs • Most other nations have adopted • Comparison with international data is hindered

  40. ICD-10 IMPACT TO PROVIDERS • Tremendous impact on both clinical and administrative areas • More extensive documentation required • Training of clinical and billing Staff • Decision support • Coding changes • Claim form changes • Not an issue that can be fully delegated to a billing company or clearinghouse

  41. WHAT CAN I DO TO PREPARE? • Talk to your vendors regarding 5010 . • Raise awareness of ICD-10 in your clinical office. • Train clinical staff on ICD-10 coding so they fully understand how to change their clinical documentation. • There is no easy way, ICD-9 to ICD-10 crosswalks are extremely controversial.


  43. MEDICAL DIRECTOR UPDATESPresenter: Thomas A. Curry, M.D. Medical Director Network Management Provider AdvocacyTransparency Initiative at BCNEPA

  44. TRANSPARENCY 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.

  45. DRIVERS • External standards – NCQA/URAC/Government • Employer Account expectations • Consumer Driven Health Plans • Other health plans including major competitors

  46. CONSUMER RESEARCH ON TRANSPARENCY • Seek a variety of information for decision making • Rely as much on patient experience as they do clinical quality indicators • Value clinical quality and patient experience over cost information

  47. CONSUMER RESEARCH ON TRANSPARENCY • Need relevant, understandable and actionable quality information • Want a credible, comprehensive source for provider information

  48. GOAL To provide clinical measures and subsequently cost measures, with a peer group comparison that is: • Fair • Meaningful • Usable

  49. PROCESS • Professional community will be involved in the development and testing of product. • Professional community will have the ability to view and comment prior to member notification.