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PROVIDER RELATIONS SEMINAR APRIL 2007. Seminar Agenda. Welcome – Jeanne Wisnewski, Director Provider Relations First Priority Life Insurance Company (FPLIC) – Overview and Product Transition Billing Information – BCNEPA, FPH and FPLIC NaviNet Enhancements

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Presentation Transcript
seminar agenda
Seminar Agenda
  • Welcome – Jeanne Wisnewski, Director Provider Relations
  • First Priority Life Insurance Company (FPLIC) – Overview and Product Transition
  • Billing Information – BCNEPA, FPH and FPLIC
  • NaviNet Enhancements
  • “Blue” Updates – BCNEPA, FPH, FPLIC and HMBS
  • Medicare Advantage PPO (Freedom Blue)
fplic agenda
FPLIC Agenda
  • Overview of company, product and networks
  • Network recruitment
  • Service Authorization Process
  • Claim Submission/Adjustments/NaviMedix
  • Remittance Advice/payments
  • Member Services
  • Questions – All
fplic handouts
FPLIC Handouts
  • Overall Precert grid for all FPLIC Products
  • Benefit Grids
  • Remittance Advice/EOBs
  • Key Information – January and April 2007 Provider Bulletins
fplic background
FPLIC Background

First Priority Health Life Insurance Company


  • Branded
  • BCNEPA/Highmark ownership
  • BCNEPA is the managing partner
  • Replacing ACII product – formal withdrawal of this product from the market place – PID notified
  • Transition of Traditional/Major Medical product – May 2007
fplic service area products
FPLICService Area & Products
  • Geographical Service Area – 13 counties only


  • BlueCare PPO: - QFG
    • Market entry May 2007
  • BlueCare PPO QHDHP: - QFG
    • Group high deductible plan
    • Market entry January 2007
    • Designed for a Health Savings Account (HSA) – BUT FPLIC will NOT be managing – up to employer or individuals to decide if necessary and implement with financial institution.
fplic products cont d
FPLIC Products Cont’d


  • BlueCare Direct: - QFD
    • PPO non group
    • Medically Underwritten
    • Individual Contracts
    • For Uninsured
    • Market entry April 2007
  • BlueCare PPO Individual Conversion: - QFC
    • PPO non group
    • Must be in group for 3 months to qualify for this product
fplic products cont d1
FPLIC Products Cont’d


  • BlueCare Individual Conversion: - QFC
    • PPO non group
    • Alpha prefix QFC
    • Must be in group for 3 months to qualify for this product
    • Not approved by PID at this time
  • BlueCare Traditional: - QFT
    • Groupproduct
    • Transition beginning with May 1, 2007 renewals
    • Continued transition through May 2008
    • Not a PPO, but a traditional product
fplic products cont d2
FPLIC Products Cont’d


  • BlueCare Comprehensive: - QFM
    • Groupproduct
    • Transition beginning with May 1, 2007 renewals
    • Continued transition through May 2008
    • Not a PPO, but a traditional product
fplic network
FPLIC Network


  • Existing BlueCross facilities with some extensions to lab and

radiology providers


  • Foundation is HMO network + Geisinger and other

professionals CRNA, CRNPs, primary/specialty physicians not

currently in the HMO network

* Executed Traditional/Major Medical contracts

Special Circumstances:

  • Mental Health facilities – foundation is HMO Network
  • Independent Radiology centers – foundation is HMO Network with some extensions
  • Sleep Centers – foundations is HMO Network
fplic network cont d
FPLIC Network Cont’d


  • FPLIC members OOA use Highmark Premiere Blue Network & any Blue facility network
  • If OOA and directly contract with FPH or FPLIC, would submit as previously instructed


  • NO hardcopies
  • All online via BCNEPA Corporate website,
fplic network recruitment applications
FPLIC Network Recruitment & Applications

Network Recruitment/Applications:

  • HMO comparison report to Premiere Blue – fallout→ sent


Requests for Applications:

  • Will use the same process as always
fplic prior authorization
FPLIC Prior Authorization

Prior authorization may be called in, faxed or

submitted via BCNEPA NaviNet:

Utilization Management Department

Blue Cross of NEPA

8:00 a.m. to 4:00 p.m. Monday through Friday

BlueCare Traditional/1-800-638-0505

BlueCare PPO/1-866-262-5623

Fax Number 570-200-6788

Note: FPLICdoesnot require initial approvals (Blue Cross Admissions)

For in-patient admissions, SNF, home health or hospice claims.

fplic prior authorization cont d
FPLIC Prior Authorization Cont’d


- BC Utilization Management Department bases its decision on specific

criteria to determine medical necessity.

- Criteria is available to BlueCare providers upon request.

- Criteria may be requested by contacting or faxing the BC Utilization

Management Department with the following information:

- Member Name - BlueCare identification number

- Date(s) of service -Date(s) of denial

- Facility where services were rendered

Blue Cross of NEPA/BlueCare

19 N. Main Street

Wilkes-Barre, PA 18711-0302

Phone Number: 1-866-262-5623

Fax Number: 570-200-6788

fplic prior authorization cont d1
FPLIC Prior Authorization Cont’d


  • Business hours/non-business hours
  • Prior Authorization Notification Letter
  • Prior Authorization Appeal – If the member or attending physician disagrees with the Utilization Management Department’s determination of medical necessity, the attending physician may appeal the determination by:
    • Medical Director - 1-800-462-0900 within 24 hours of the denial
    • An appeal may also be requested in writing with supporting medical records within 60 days of the denial letter, and submitted to:Regulatory Compliance Department


19 N. Main Street

Wilkes-Barre, PA 18711-0302

fplic prior authorization cont d2
FPLIC Prior Authorization Cont’d

In-Area Admissions - Prior Authorization (DRG Facilities):

Note:The FOCUS Prior Authorization list for this product line is the same as

the current BC FOCUS Prior Authorization list. The only additional services are

abdominoplasty/panniculectomy (15830 CPT and 86.83 ICD-9) and transplants.

  • Focus Prior Authorization requires that targeted diagnosis and/or procedures
  • Focus Prior Authorization Diagnosis/Procedure List (requires prior authorization only if patient is admitted as an inpatient).
  • Prior Authorization is required only for the specific medical/surgical procedures outlined in your handout. Prior authorization approvals are valid for up to 60 days from initial request.
  • The hospital shall be responsible for furnishing to BC’s Prior Authorization Department any required medical information relative to the prior authorization process.
fplic prior authorization cont d3
FPLIC Prior Authorization Cont’d

In-Area Admissions – Prior Authorization (DRG Facilities)


  • Denial of services may occur. Please refer to your BlueCare Provider Policy and Procedure Manual, Admission/Discharge – Section E, Page 3, under Responsibility of Participating Hospital.
      • In the event that one of these situations occur, the participating hospital may not charge either Blue Cross or the member for services rendered with respect to such admission.
fplic prior authorization cont d4
FPLIC Prior Authorization Cont’d

Acute Inpatient Services:

  • Elective Admissions
  • Emergency/Urgent
  • Short Procedure Unit (SPU) – only complications

requiring inpatient stay need pre-admission


fplic prior authorization cont d5

Behavioral Health Care Services -

      • All inpatient and partial hospitalization psychiatric and chemical dependency admissions require pre-admission certification.
      • All out-of-area inpatient admissions regardless of group or individual contract require pre-admission certification.
  • Contact: Regional Referral Center: 1-800-577-3742
FPLIC Prior Authorization Cont’d

Requires Prior Authorization

  • Skilled Nursing Facility
  • Home Health Services
  • Inpatient Acute Physical Rehabilitation Hospitalization

Note: As of January 1, 2006, providers who are NaviNet

enabled MUST submit the initial prior authorization request for

home health or inpatient rehabilitation services via NaviNet.

  • Home Infusion Services – Certain home infusion benefits

require prior authorization by the Blue Cross Pharmacy

Management Department.

      • Phone Number – 1-800-722-4062
      • Fax Number – 570-200-6870
  • Behavioral Health Care Services -
      • All inpatient and partial hospitalization psychiatric and chemical dependency admissions require prior authorization.
      • All out-of-area inpatient admissions regardless of group or individual contract require prior authorization.

Contact: Regional Referral Center: 1-800-577-3742

fplic prior authorization cont d6
FPLIC Prior Authorization Cont’d

Out of Area Admissions:

  • ALL admissions (elective, emergency/urgent and inpatient stay due to SPU complications) to a BlueCare non-network/out-of-area hospital will require prior authorization.
  • Maternity Admissions – Prior authorization is not required for maternity admissions for BlueCare members either in or out of area.
      • If the baby is detained after the mother is discharged, prior authorization is required for out of area only.
fplic claims review
FPLIC Claims Review

Electronic Claims

  • Electronic claims will continue to be sent to Blue Cross of NEPA:
    • Through their vendor’s EDI capability, E-Premis, NaviNet, EMDEON, etc.
    • Both institutional and professional claims are submitted to Blue Cross of NEPA for FPLIC products.
  • NPI requirements have been and will continue to be sent to the providers via our ‘Provider Bulletins’.
  • Claims will then be re-enveloped by BCNEPA’s IT Dept. and sent to Highmark
  • Processed in the OSCAR system.
  • The UB92 system will not be utilized for FPLIC.
  • Blue Cross Admission Approvals will NOT be required for inpatient, SNF, home health or hospice claims for FPLIC Products.
  • Providers can register online for electronic billing via our corporate website Click on the Provider Tab and EDI registration appears on the left hand side of the screen.
  • Highmark’s Oscar system will adjudicate claims. Therefore, HBS billing guidelines are to be followed.
fplic claims review cont d
FPLIC Claims Review Cont’d

Acceptance/Rejection Reports:

Facility - There will be a separate A/R report generated on NaviNet for

electronic billing submitters, and the title will be “BlueCare Acceptance/Rejection”.

- The error codes will be in a HIPAA format.

  • It is anticipated to add a description of the code to the reports in the future.

Professional - Depends on the clearinghouse; for example, EMDEON (formerly

WebMD) has their own proprietary report.

- NDC uses the BCNEPA report;

- McKesson has no report at this time; Direct connect providers will use NaviMedix

or there is no report (there are no professionals billing us direct at this time).

fplic claims review cont d1
FPLIC Claims ReviewCont’d

Hardcopy Claims

Mail to:


P.O. Box 890179

Camp Hill, PA 17089-0179

Claims will be processed on Highmark’s system.

Note: NPI requirements have been and will continue to be sent to

the providers via BCNEPA Provider Bulletin and Highmark’s PRN

Plan Code:

All Products will utilize Plan Code 274.

fplic claims review cont d2
FPLIC Claims Review Cont’d


Institutional providers that bill on the UB92/UB04 billing form

have two (2) options:

Option 1: They can utilize the Blue Cross adjustment form that has been modified with a box titled, “First Priority Life Insurance Company” to

accommodate these adjustment requests. Highmark strongly recommends electronic submission.

Option 2: They can electronically submit bill types XX5 (late

chgs.), XX7 (adj.), XX8 (cx.)

Note: Professional providers can submit a corrected hardcopy claim as they do today.

Caution: UB92 period ends 05.23.07 – NEW UB04 format is to be used for DOS 05.23.07 forward

fplic claims review cont d3
FPLIC Claims Review Cont’d

Medical Policy and Medical Record Requests:

  • BCNEPA’s medical policies will be applied to claims, however, if there is a “gap” for a specific service, we will then revert to Highmark’s policies.
  • Medical record requests will be system generated and sent to the provider from Highmark.
    • The letter will include an address where records should be sent.
    • Claims will pend for 14 days and if no records rec’d. in that time frame, the claim will be rejected.
fplic claims review cont d4
FPLIC Claims ReviewCont’d

Provider Claim Appeals:

Institutional provider appeals should be submitted in writing to:

Blue Cross of NEPA

Regional Manager, Provider Relations

19 N. Main Street

Wilkes-Barre, PA 18711

Professional provider appeals should be submitted in writing to:

Blue Cross of NEPA

Medical Policy Dept.

19 N. Main Street

Wilkes-Barre, PA 18711

fplic claims review cont d5
FPLIC Claims ReviewCont’d

Blue Card Program:

Providers will submit as they do today, to their local Plan.

Institutional to BCNEPA and professional to Highmark.


Both professional (CMS 1500) and institutional claims can be

entered via NaviNet.

  • FPLIC line of business has been added to the dropdowns on the

survey screen of the UB92/UB04 submission transaction.

  • FPLIC line of business will also appear on the

patient search screens to indicate a FPLIC member.

* Note: As of 03.31.07 – NPIs will appear and will only appear after 05.23.07 – NO NPI – NO NAVINET SUBMISSION!

fplic payment
FPLIC Payment

Facility Payment:

  • Remittance Advice
    • All inpatient claims by patient last name
    • All outpatient claims by patient last name
    • If a provider has electronic remittance advice, “a separate ERA will be generated in NaviNet and titled “BlueCare PPO institutional”, or “BlueCare PPO Professional”.
    • If the provider currently has Blue Cross EFT/ACH, details are in progress to allow facilities to have FPLIC EFT. Target Date - May 2007.
    • If provider receives a check, all checks for FPLIC products will be a separate paper check.
  • Schedule
    • Mailing date of checks and RA’s to be determined
fplic payment cont d
FPLIC Payment Cont’d

Payment Mechanism:

  • Concurrent processing for Traditional/Major Medical only…services are adjudicated under correct line of business
  • Provider receives one payment and only one remittance advice/EOB.

Facility Payment:

  • Note: New BlueCross or Highmark Electronic Funds Transfer (EFT) Requests take 3-5 weeks from application to activation.

EFT Provider Contact:

  • Karen Klimchak – 570-200-4672
fplic payment cont d1
FPLIC Payment Cont’d

Professional Payment:

  • Explanation of Benefits (EOB)
    • Sorted by patient’s last nameNote:Will eventually be sorted by product, then by patient’s last name.
    • Schedule
      • Mailing date of checks and EOB’s to be determined.
  • Payment Methods
    • Check if currently receiving
    • ACH/EFT target May 2007 ** If have ACH through Highmark currently!
      • It is anticipated to be offered later in 2007 to remaining network.
fplic payment issues
FPLIC Payment Issues

Payment Open Issues:

  • Whose business rules are followed?
    • Highmark providers and BCNEPA facilities may receive both an 835 and hard copy.
    • FPH providers may receive one or the other – not both.
fplic customer services
FPLICCustomer Services

BlueCare Service Representatives

(formerly Customer Service Representatives)

Member Customer Service –

1-888-827-7117 Blue Care Trad/Maj Med

1-866-262-5635  Blue Care PPO and Blue CareComprehensive

  • Help members understand their benefits and exclusions,
  • Answer eligibility and claims questions,
  • Assist members in filing formal complaints and grievances.

Provider Customer Service – 1-866-262-5635

  • Assist providers with claims questions,
  • Assist providers with member eligibility and benefit questions,
  • Available through NaviNet SM.


  • Monday through Friday 8:00A.M. to 5:00 P.M.


billing information
Billing Information


  • NPI and Taxonomy Code
  • NUCC-1500 Claim Form
  • UB04 Claim Form
npi at a glance
NPI at a Glance

Required as a result of HIPAA Regulation

  • Individuals and groups must apply
    • Complete on-line application
    • Download and print application


    • Call 1-800-465-3203 to request an application
npi cont d
NPI (cont’d)
  • Register your NPI with all payers
  • Identify the payers’ format requirements
  • Contact your practice management software vendor to initiate any necessary format changes
  • NPI required on electronic claims 5/23/07
taxonomy code
Taxonomy Code
  • Required as a result of HIPAA Regulation
  • Must be reported on the claim
  • Must match confirmation letter

(Taxonomy codes are assigned by payer based on credentialing – FPH may differ from Highmark)

For a list of valid taxonomy codes:

claim submission
Claim Submission
  • Paper Claims
    • Proper alignment
    • Data in the boundaries of the boxes
    • Legibility
    • Right information in the right fields
    • All required fields completed
    • NUCC-1500 Form required 6/1/07
claim submission paper
Claim Submission - Paper
  • Only 6 service lines (shaded lines above the

service lines are for supplemental information


  • Regularly change your print ribbon/print cartridge to ensure the print is dark enough to be read by scanner
  • Avoid using special characters-i.e.: $ - /
  • Use “X” for yes/no blocks
  • Do not attach superbills
  • Consider changing to electronic submission
claim submission1
Claim Submission
  • Electronic Claims
      • Right information in the right fields
      • Review acceptance/rejection reports
      • Correct errors and resubmit electronically

Please, do not drop rejected electronic claims to paper

      • Highmark accepts secondary claims and claims with paper attachments electronically. Information is available at:
nucc 15001

Field 24 (i) – describes what type of number

you’re reporting in field 24(j):

On the shaded line:

  • Use “ZZ” if you report the provider’s taxonomy code
  • Use “1G” if you report the provider’s UPIN #
  • Use “G2” if you report the provider’s FPH #
  • Use “1B” if you report the provider’s Highmark / FPLIC #


In the unshaded area, note that 24(i) is pre-filled with “NPI”

Leave field 24(i) blank if you are reporting the provider’s NPI #

nucc 15002

Field 24 (j) – the identifying number of the

individual rendering the service(s)

On the shaded line:

Enter the individual’s taxonomy code, UPIN # or their

payer assigned insurance provider ID# based on the

reported qualifier.

Do not insert any spaces between shaded fields 24(i) and



On the unshaded line:

Report only the provider’s NPI#

nucc 15003

Field 32(a)

Enter the NPI# of the facility where the services

were performed, followed by the associated

taxonomy code in Field 32(b)

Remember to include the “ZZ” qualifier in field

32(b) followed immediately by the taxonomy


nucc 15004

If the facility NPI# is not reported in 32(a), then in Field

32(b), use the same logic applied to the shaded fields in

24(i) and 24(j)

Report the qualifier first (1G if you’re using the

UPIN,G2 for the FPH #, or 1B for the HMBS#) and the

appropriate identification number

For example, G2 means I’m using the FPH provider #,

and 800053 is the actual provider number. In field 32(b),

I would report: G2800053

nucc 15005

For First Priority Health Claims:

Fields 33(a) and 33(b):

33(a) – Enter the performing provider’s NPI#

(Individual NPI only – not the group’s NPI)

33(b) – Enter “ZZ” followed immediately by the

performing provider’s taxonomy code

nucc 15006

For Highmark Blue Shield and FPLIC Claims:

Fields 33(a) and 33(b)

33(a) – Enter either the performing provider’s NPI# (if a solo practice) OR the group’sNPI# if applicable

33(b) – Enter “ZZ” followed immediately (no spaces) by the taxonomy code of the entity reported in field 33(a).

If no NPI, report the qualifier first (1G,G2,1B) and the

appropriate identification number in 33(b).

ub 04
  • Replaces UB-92
  • Must be used for all institutional paper claims submitted beginning 5/23/07
  • Is conceptually similar to UB-92
  • Has added, deleted, and/or created fields
ub 041


Locator 02 = Pay-to name and address

Locator 29 = Accident State

Locator 56 = NPI Billing Provider

Locator 66 = Diagnosis and Procedure Code Qualifier

Locator 71 = Prospective Payment System (PPS) Code – report the DRG code

Locator 81 = Code-code field – Report the provider’s taxonomy code, preceded by the 2 character qualifier “B3” (no space)

ub 042


Locators 39-41 – New value codes created:

Code 80 = Covered days (formerly locator 07)

Code 81 = Non-covered days (formerly locator 08)

Code 82 = Co-insurance days (formerly locator 09)

Code 83 = Lifetime reserve days (formerly locator 10)

Locator 51 – Health Plan ID – not required

Locator 57 – FPH, BCNEPA, Medicare Provider ID#

  • NPI:
  • Call 1-800-465-3203 to request an application

Taxonomy Codes:

A listing of HIPAA compliant taxonomy

codes is available through:

Washington Publishing Company


1500 Claims

Reference Instruction Manual is available to download at no charge at

First Priority Health Claim Requirements

  • Provider Bulletin, September, 2006 (Paper)
    • Provider Center – electronic claim guidelines
    • All providers are now required to register with us prior to being setup for electronic billing.

FPLIC and Highmark Blue

  • Provider Resource Center
    • Administrative Reference Materials
      • Highmark Blue Shield Office Manual – Chapter 5
  • EDI Services – Specifications
    • Provider EDI Reference Guide

Highmark’s EDI Trading Partner Web site is dedicated to helping you become electronically enabled.

navimedix updates
NaviMedix Updates

NaviMedix Updates


(NaviNet, Provider Portal)

Refer to Handouts



updates updates updates
  • BCNEPA Updates
  • Highmark Blue Shield (HMBS) Updates
  • First Priority Health (FPH) Updates
bcnepa updates
BCNEPA Updates

BCNEPA Provider Center now available online

  • Previously secure access or through NaviNet
  • Access to updates, Provider Bulletins, Manuals,

contact information, forms

hmbs updates
HMBS Updates

Highmark Blue Shield No Longer Processes

Professional Claims For IBC

  • April 2006 Highmark announced Independence Blue Cross processes claims relating to Personal Choice PPO
  • BCNEPA/Highmark does not have access to claim information
  • New “Imaging” address for paper claims:

Personal Choice Claims

PO Box 890016

Camp Hill, PA 117089-0016

hmbs updates1
HMBS Updates

Highmark Blue Shield No Longer Processes

Professional Claims For IBC…Continued…

  • NAIC 54704 for electronic billing
  • Provider ID clarification-submit your Highmark provider number, not one that may have been issued in error by IBC
  • Daily feed of provider file information
  • Tax ID reporting errors
  • Provider Unit (800) 332-2566
  • eBusiness Help Desk (215) 241-2305
fph updates
FPH Updates

First Priority Health eliminates PAR Referral

Process March 31, 2007

  • 12/2006 Provider Bulletin-revised Non PAR Provider Request Form. PCP or Specialist may complete.
  • Behavioral Health services continue to require authorization from the Regional Referral Center

1 (800) 599-2428

  • Members continue to choose a PCP
  • Capitation continues for PCPs
non participating authorization
Non Participating Authorization
  • Authorizations may be made telephonically by calling 1-800-962-5353.
  • Office will be called with the determination
  • Written determination will also be mailed
  • Unable to Fax Back determination
all blues line of business
All ‘Blues’ Line of Business

Administrative Policy Reminder:

  • Services provided to Immediate Relatives are Excluded from Coverage
  • Applicable to BCNEPA, Highmark Blue Shield, First Priority Health, and First Priority Life Insurance Company (FPLIC)
  • Claims will deny as non-covered. Payments made in error will be re-couped
all blues line of business1
All ‘Blues’ Line of Business
  • “Immediate Relative” is defined as:
  • Any member within the same legal residence of the provider, OR
  • Husband or wife
  • Natural parent and child
  • Adoptive child and adoptive parent
all blues line of business2
All ‘Blues’ Line of Business
  • “Immediate Relative” continued:
  • Stepparent and step child
  • Father in law, mother in law, son in law, daughter in law, brother in law, and sister in law
  • Grandparent and grand child
  • Sibling, stepbrother and step sister
all blues line of business3
All ‘Blues’ Line of Business

Updating Provider File Information:

  • Updates managed by BCNEPA for all lines of business
  • Address, Assignment Accounts, additional locations, etc.
  • Blue Cross of Northeastern Pennsylvania

Provider System Support

19 North Main Street

Wilkes-Barre, PA 18711

1(800) 451-4447

(570) 200-6880 Fax



freedom blue1
  • What is Medicare Advantage?
  • Who is eligible ?
  • Membership Information
  • Benefits
  • Contact Information
  • Medical Management
  • Radiology Management Program
  • Electronic Tools
  • Miscellaneous
what is medicare advantage
What Is Medicare Advantage?
  • Program administered by The Centers for Medicare and Medicaid Services (CMS)
  • Formerly called Medicare+Choice
  • Provides all the same benefits of Medicare plus supplemental benefits (i.e. Dental, Vision, RX, etc.)
  • Medicare Advantage Preferred Provider Organization (PPO)
  • Product from Highmark Blue Shield in association with BCNEPA.
  • Offers Medicare-eligible individuals the convenience of a PPO arrangement through which covered health care services are reimbursed at the highest level when member received these services from network providers.
who is eligible
Who is Eligible?
  • Permanent county residence: NEPA - Luzerne and Lackawanna counties
    • Filed for expansion in remaining 11 counties for 01/01/08
  • Eligible for Part A and enrolled in Part B
  • Cannot be medically determined to have End Stage Renal Disease (ESRD)
freedom blue member id cards

Sample Medical ID Card

freedom blue member id cards cont d
FREEDOM BLUE Member ID Cards Cont’d

Sample Prescription Drug ID Card

freedom blue membership information
FREEDOM BLUE Membership Information
  • Freedom Blue Prefixes: FER (NEPA), FEM (Highmark)
  • The current membership in Luzerne and Lackawanna counties is 1800+.
freedom blue benefits
  • Primary Care Physician Selection:
    • Not required to select a PCP -- encouraged to maintain a relationship with a network “preferred” provider
  • No referrals
  • Maximum coverage for in-network care
  • Out-of-network care covered at a reduced level and includes deductible/coinsurance
  • Refer to Handout for additional information
freedom blue benefits cont d
FREEDOM BLUEBenefits Cont’d

Offers Traditional Medicare Benefits…and More

  • Vision
  • Prescription Drugs
  • Immunizations
  • Routine Annual Physical Exams
  • Dental
  • Podiatric Care
  • Chiropractic Care
  • Routine Hearing
freedom blue benefits cont d1
FREEDOM BLUEBenefits Cont’d

FreedomBlue Options and Prices

Basic = $0.00

Value = $23.00

Standard = $66.00

Deluxe = $94.00

freedom blue benefits cont d2
FREEDOM BLUEBenefits Cont’d

FreedomBlue Contact Information

Member Service (HMBS)

  • Questions & Enrollment: 1-866-306-1061

Provider Customer Service (HMBS)

  • Claims/Benefits/Eligibility: 1-866-588-6967

Medical Authorizations (HMBS)

~ Healthcare Management Services ~

1-800-547-3627, option #3

Electronic Billing: 1-800-992-0246

Refer to Handout for additional contact information

freedom blue medical management
FREEDOM BLUEMedical Management

Medical Management Requirements

Authorization Process

  • Provider’s responsibility--obtained before services are rendered or within 48 hours of emergency admission
  • If authorization is not obtained, claim will reject and member is held harmless
  • To obtain an authorization, contact Highmark’s Health Care Management Services (HMS) team:

1-800-547-3627, option #3

freedom blue medical management cont d
FREEDOM BLUEMedical Management Cont’d

Medical Management Requirements

Authorizations are Required for:

  • Inpatient admissions (Hospital, SNF)
  • Transfers
  • Home Health
  • Certain outpatient services
    • Reference the “Procedures/Durable Medical Equipment that Require Authorization” list
  • Outpatient therapies
  • Certain DME/O&P items
freedom blue radiology management program
FREEDOM BLUERadiology Management Program


  • Effective January 1, 2006 any Medicare Advantage provider who wants to perform radiology services must be privileged by Highmark Blue Shield in order to bill and be reimbursed for services.
  • Imaging providers must submit privileging applications and be approved to offer certain advanced imaging procedures to FreedomBlue members.
freedom blue radiology management cont d
FREEDOM BLUERadiology Management Cont’d

Prior Authorization

  • Required for select CT, MRI, MRA and PET scans.
  • Must be obtained by the ordering physician
  • Must utilize Highmark-Sponsored NaviNet application (if available). If not available can call NIA via their toll-free number – 1-866-731-2045, option 5.
    • NIA is available M – F, 8 am to 8 pm
  • Prior authorization only applies to FreedomBlue Members in 13 county BCNEPA region, not for any Highmark commercial members.
radiology management cont d
Radiology Management Cont’d
  • Intended to ensure quality and proper use of diagnostic imaging
  • Clinical guidelines available at
  • Refer to
    • Clinical Criteria
    • Application
    • Complete listing of services requiring prior authorization
    • Radiology Prior Authorization Reference Guide
electronic tools
Electronic Tools

Provider Center available via or BCNEPA sponsored NaviNet:

  • Bulletins and Articles
  • Reference Materials
  • Administrative Guides
  • Medical Policy
  • Radiology Management Program
  • Forms
  • Pharmacy Information
  • Blues on Call
      • 24 hour member support health resource
  • Silver Sneakers
      • Unique exercise physical activity and social oriented program
      • Offers member free access to local community centers.
  • Prescription Drug Discount Program
      • Members receive instant savings on most brand/generic drugs at Premier Network Pharmacies throughout the service area.


  • Dependable revenue stream with timely and accurate payments.
  • Direct payment to the provider, eliminating need to file secondary claims with Medigap.
  • Exceptional provider support.