Highmark blue cross blue shield wv may 15 2014
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Highmark Blue Cross Blue Shield WV May 15, 2014. HEALTH CARE EXCHANGE/ MARKETPLACE. WHAT IS IT?

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Health care exchange marketplace


  • The Affordable Care Act (ACA) requires that each state establish an online marketplace, referred to as a health insurance marketplace or exchange, through which qualified individuals may enroll in qualified health plan coverage. Eligible individuals that qualify for financial assistance to purchase coverage must purchase their coverage through a marketplace in order to receive the cost savings, which may include advance premium tax credit or cost-sharing reductions for those individuals who qualify.

  • The marketplaces, or exchanges, were scheduled to permit consumers in each state to begin the plan selection and enrollment process as early as October 1, 2013 for coverage that began January 1, 2014, the date when the individual coverage mandate became effective.

  • Health insurance marketplaces will support functions other than permitting qualified individuals to shop for qualified health plans. Consumers can also find out if they are eligible for public health programs such as Medicaid, and they can take steps to enroll in those programs.

Health care exchange products
Health Care Exchange Products

  • Our Products & Formularies

  • ACA sets the requirements for Qualified Health Plans (QHPs) in terms of metal levels, out-of-pocket maximum limits, essential health benefits and more. Health plans on the exchanges are offered in a tiered format with several plans in each tier to choose from. Plan tiers are based on metal levels that match the percentage of costs covered (the actuarial value of the plan) as follows:

  • Bronze (60 percent) Silver (70 percent)

  • Gold (80 percent) Platinum (90 percent)

  • Essential health benefits must be covered under each tier.

  • ambulatory patient services

  • emergency services

  • hospitalization

  • maternity and newborn care

  • mental health and substance use disorder services, including behavioral health treatment

  • prescription drugs

  • rehabilitative and habilitative services and devices

  • laboratory services

  • preventive and wellness services and chronic disease management

  • pediatric services, including oral and vision care

Health care exchange products1
Health Care Exchange Products

  • Helpful Tips……..

  • No separate contract agreements to participate

  • Follows Highmark WV Commercial Network

  • Medical Policies

  • Authorization process

  • Management programs

  • Services requiring authorization

Highmark Member Cards

Cards will look the same as other lines of business for Highmark WV. Copays will be listed but not metallic tier.NaviNet should be utilized to verify eligibility and covered benefits.

How will this affect you and your provider
How will this affect you and your provider….

Alpha Prefixes Specific to Market Place Policies

(subject to change)

ZPL-On Exchange

ZPI- Off Exchange


  • The Affordable Care Act (ACA) requires a 90-day premium delinquency grace period for individuals who purchased insurance through the Health Insurance Marketplace (HIM) and received an Advanced Premium Tax Credit (APTC).

  • Within this 30-day period, the member is placed in delinquency and the first delinquency letter is sent to the member. Claims are still being paid to providers at this point.

  • After 60 days with no premium payment(s) made, a second delinquency letter will be sent to the member, with the future termination date if payment is not made in full. Claim payment to providers is suspended at this point.

  • If 90 days pass and the account is not paid up to date, the member's coverage will be terminated and the claims rejected for payment back to the provider. Once a member's coverage is terminated for non-payment of premiums, he/she is responsible for claim payment to the provider.

Provider relations representatives servicing areas january 1 2014

* Melanie Clyde and Joe Lippoli share Mon County – Melanie is responsible for WVU Hospital and connected Physicians as well as Mon General and connected physicians.

Highmark west virginia website
Highmark West Virginia website

  • www.highmarkbcbswv.com

  • Resource Center

  • Health Care Reform

Network participation

  • The WVFH network is an extension of the Highmark BCBS WV PPO Network. Existing PPO providers who participate with Medicaid are offered participation with WVFH by agreeing to the amendment of the current agreement with Highmark WV

  • Reimbursement for covered services is 105% of West Virginia Medicaid

Primary care providers
Primary Care Providers

  • Each West Virginia Family Health member will choose a Primary Care Practice as their Patient Centered Medical Home.

  • The PCP works in conjunction with the member to coordinate all appropriate medical care.

  • Members are able to change PCP’s on a monthly basis if requested.


  • In certain instances, members do not require a referral from the PCP to see a network specialty care practitioner.

  • Members may self refer for the following services:

    • OB/GYN Services

    • Family Planning Services (Family Planning services do not have to be rendered by a Network provider)

    • Dental services

    • Routine vision

    • Chiropractic services (an authorization must be obtained by the chiropractic office, including the initial evaluation)

    • Mental health/substance abuse services

Claims and billing
Claims and Billing

  • Bill all appropriate modifiers

    • Bill all encounters, regardless of payment expected

    • Timely filing Criteria

      • Initial Bills must be received within 12 month of date of service or payment from the primary carrier.

        • All EPSDT claims and primary care services should be submitted within 60 calendar days from the date of service to permit accurate member outreach.

      • Corrected claims or requests for review must be received within 180 days from the date of the remittance advice

    • Claims submitted with any attachments, such as EOBs from Primary Carriers must be submitted on paper

      West Virginia Family Health – Claim Department

      P.O. Box 69319

      Harrisburg, Pa. 17106

Claims and billing1
Claims and Billing

  • Electronic Billing

    • Electronic claims accepted through Emdeon or Relay Health

    • Please refer to the following grid for Emdeon Payer ID’s and RelayHealth CPID’s (clearinghouse Process ID):

    • Hospital should include their West Virginia Family Health issued legacy number in your 837I submissions

      • Loop 2010BB REF01 with a qualifier of 'G2‘

      • REF02 should be WVFH Issued ID#

  • PCP’s and Specialists should bill under their individual NPI#

Wvfh provider relations representatives servicing areas january 1 2014

West virginia family health website
West Virginia Family Health Website

  • www.wvfh.com

  • Policy & Procedure Manuals

  • Complete Formularies

  • Online Provider Directory

  • WVFH Forms


  • Highmark has engaged the services of the Matrix Medical Network to help us complete health risk assessments for Medicare Advantage Plan beneficiaries

  • There is no cost to the member

  • Assessments help Highmark on-going commitment to quality care

Highmark wv workshop schedule
Highmark WV Workshop Schedule

  • June 10th Charleston Marriott Salons A&C on the 2nd floor

  • June 11th Huntington Pullman Plaza  Virginia/Maryland Rooms

  • June 17th Bridgeport Conference Center  Ballroom

  • June 18th Wheeling Oglebay Conference Center Wilson Lodge Banquet Rooms 1, 2 and 3

Fy 2015 quality blue hospital program focus streamlined to six components
FY 2015 Quality Blue Hospital Program FocusStreamlined to Six Components



Measures included in the quality bundle 20 cms star measures
Measures included in the Quality Bundle: 20 CMS Star Measures

* Measures in blue denote Static measures

THANK YOU Measures

For questions or additional information please contact:

Joyce Landers 304-347-7730 [email protected]

Cindy Heiskell 304-347-7717 [email protected]