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Provider Conferences – 2009Welcome and thank you for joining us –We’re glad that you are here!An independent licensee of the Blue Cross and Blue Shield Association
Agenda Updates and reminders Inter-Plan Programs Updates (BlueCard ) Improving member’s health Pharmacy and medication bcbsnc.com/providers/ Blue e SM2
Add title for transition slideUpdates & reminders3
National provider identifier (NPI) Blue Cross and Blue Shield of North Carolina (BCBSNC)is compliant with the National Provider Identifier (NPI)mandate as required by the Health Information Portabilityand Accountability Act of 1996 (HIPAA). Under HIPAA, providers and health insurance carriers areconsidered covered entities and were instructed to complywith the NPI mandate effective May 23, 2008. As a result,electronic transactions received by BCBSNC without anNPI will be rejected.4
Member ID cards We’ve redesigned our member ID cards, as part of anoverall Blue Cross and Blue Shield Association effort tostandardize ID cards for all Blue members nationwide. The Association wants to ensure that the benefitinformation on the cards is consistent and easy to find andunderstand. Additionally, a North Carolina senate bill, which becameeffective January 1, 2009, requires that all insurers listcertain copayments on ID cards, as well as, the effectivedate of coverage or the issue date of the card.5
Member ID cardsSample6
Print Verification of Coverage (VOC) We’re adding to the My Member Services page on ourWeb site, tools that allow our members to downloadand print interim proof-of-coverage when awaiting aBCBSNC member ID card.Manage Your Benefits andAccountClaimsRequest an ID card,change your contactinformation and more.View your claims,check your benefits,download forms andmore.7
Provides minimumnecessary memberdata for serviceeligibility Subscriber name and ID Member names and IDs Group number Product Effective date In-network member*responsibility Dental coverage indicator Claims filing addresses Customer service phone*number8
Member ID cardsSMSMBlue Medicare HMO and Blue Medicare PPO plansBCBS Associationsymbols andBCBSNC textBlue MedicareHMO or PPOdesignationBlue Medicarealpha-prefix: YPWJ YPFJ YPJJPARTNERSNational HealthPlans of NorthCarolina, Inc.9
Blue Medicare HMO & Blue Medicare PPOSMSM Only providers directly contracted with PARTNERS areconsidered as in-network for Blue Medicare HMO andBlue Medicare PPO .SMSM– BCBSNC participating providers that are not contracted withPARTNERS can provide services to Blue Medicare PPOmembers as part of the member’s PPO out-of-network benefits.SM– Blue Medicare HMO members have no out-of-network benefits(except for emergency care).SM– Claims submitted to BCBSNC for Blue Medicare HMO and PPOmembers in error will be returned to the submitting provider orelectronic clearinghouse. This includes both paper and electronicclaims.10
2009 Service area for Blue Medicare HMO andBlue Medicare WATAUGABERTIEDAVIDSONHALIFAXNEW DKINCALDWELLEDGECOMBEIREDELL11
NCHC Changes North Carolina Health Choice for Children (NCHC)members were issued new ID cards the last few weeks of2008, which became effective January 1, 2009. Claims for NCHC members previously processed on ourLegacy claims system, are now being processed on ourmuch newer Power MHS system (starting 01/01/09, forservices provided on or after January 1).12
BCBSNC Medicare Supplement and MedicareHigh Option programs Effective January, 1, 2009, BCBSNC MedicareSupplement received a new name – Blue MedicareSupplement. Also effective 01/01/09, processing of Blue MedicareSupplement and Medicare High Option claims transitionedfrom our Legacy claims system to the AMISYS claimsprocessing system (for services provided on or after01/01/09).13
Credentialing and re-credentialing On May 1, 2008, BCBSNC updated the minimum liabilityinsurance requirements for initial credentialing and recredentialing of professional providers. The minimum insurance liability limits became one-milliondollars per occurrence / three-million dollars aggregate(previously one-million dollars per occurrence / onemillion dollars aggregate). The limits increase went into effect May 1, 2008, for allnew credentialing applications and became effective onMay 1, 2009 for all re-credentialing applications.14
Paper remittances – going away As part of BCBSNC’s continuing efforts to become a“greener” company for North Carolina, we’ve changed thestandard delivery method for provider payment details bydiscontinuing use of paper remittance as of April 19,2009. Forms of discontinued paper remittance include:– Explanations of Payment (EOP)– Notices of Payment (NOP)– EFT Paper Voided Checks & Payment Summary Pages(EFT information for providers enrolled for electronic fundstransfer)15
Sign-up for EFT online via Blue eSM As of April 2009, providers have the ability to sign-up forelectronic funds transfer (EFT) on-line with Blue e .SM This new sign-up alternative makes it easier for providers toreceive the fastest receipt of eligible payments for theirBCBSNC claim submissions. Once we have received and processed a claim, EFT paymentis sent directly to the bank account of your designation.– Payments are sent through an automated clearing house andtypically take up to two days to post, which is a much fasterprocess than a conventional check cycle and our mailing to yourbank to process and deposit.16
Level I Provider Appeal In August 2008 BCBSNC implemented a new providerappeal process, which replaced the post-service ProviderCourtesy Review with a Level I Provider Appeal for billingdisputes, medical necessity denials, and denials for nopreauthorization of an inpatient stay. This process allows providers to appeal without gainingconsent from the member.– Pre-service Provider Courtesy Reviews handled by the MemberHealth Partnership Operations department did not changed.17
Level II Provider Appeal Effective November 21, 2008, Physicians, Physician Groups,and Physician Organizations may file a Level II Post-ServiceProvider Appeal for medical necessity or billing disputes. Level II Provider Appeals are conducted by an IndependentReview Organization, and there is a filing fee associated withall requests for a Level II Post-Service Provider Appeal. Requests for Level II Post-Service Provider Appeals must besubmit in writing and received by BCBSNC within ninety (90)calendar days of the date of the Level I Post-Service ProviderAppeal denial letter.18
Settlement Agreement BCBSNC has previously communicated information related tothe settlement agreement Love, et al. v. Blue Cross Blue ShieldAssociation, et al., formerly Thomas, et al. v. Blue Cross BlueShield Association, et al. BCBSNC has made and is continuing to make enhancementsto support greater transparency and operational efficiency. For information about the Thomas/Love Settlement Agreementand what BCBSNC is doing to comply, access BCBSNC onlineat bcbsnc.com for public information or log in to Blue e forsecured information.SM19
Fee schedules available through Blue eSM Beginning April 21, 2009, participating physicians withaccess to Blue e will have the ability to view their feeschedule through a new transaction located in Blue e .SMSM20
Warehouse requisition no longer available Due to a reduction in the forms offerings, BCBSNCeliminated the Provider Warehouse Requisition (B117Form) in 2007. The requisition form is no longer accepted by MooreWallace and all copies in circulation should be destroyed. Forms are available for copying from the Blue BookProvider e-Manual, which is available on the BCBSNCWeb site for providers.SM21
Add title for transition slideInter-Plan Programs Updates(BlueCard ) 22
BlueCard claims processing enhancements In November 2008 Inter-Plan Programs completed thetransition of BlueCard host claims processing functionsfrom the Legacy claims system to our Power MHSsystem. Using the Power-MHS system, we are now ableto: – Improve data and financial claims accuracy through the use of asingle pricing source– Increase claims processing speed through automation thatreplaced manual processes– Deliver pricing that meets with Thomas compliance23
BlueCard claims processing enhancements Improvements with the Power MHS produced EOPs forBlueCard claims include: – Clearer descriptions on column headers– Serial numbers assigned to claims print on the EOPs (Serial numbers of claims processed by BCBSNC, as the Hostplan, begin with the number 310)– Enhanced remark codes with easy to understand descriptions– Claim reversal information displays on the EOP 24
BlueSquared (Blue2) BlueSquared (Blue2) is a Web application that enables BluePlans to view, send and track transactions related to the receiptof medical records in real time, as well as, access claims statusand route appeals electronically to BlueCard member’s homeplans. Performance enhancements through BlueSquared(Blue2):– Improved exchange of informational messages, medicalrecords and miscellaneous attachments for BlueCardclaims – Improved tracking of misrouted claims– Faster claim status inquiries for Inter-Plan claims25
PPA & radiology management services BlueCard members from non-North Carolina BC and/or BSPlans are not included in the BCBSNC radiology managementprogram administered through American Imaging Management(AIM). However, it’s important to always verify a member’seligibility and prior authorization requirements, as a membermay be enrolled in a benefit coverage plan that includesauthorization prior to receiving certain radiological services. To verify: – Call the number on the member’s identification card– Call 1-800-676-Blue– Blue eSM26
Bundling rules Just like other claims filed to BCBSNC, BlueCard claimsshould never be split billed or filed in partial increments: – Claims should be filed utilizing valid CPT and/or HCPCScodes– Claims are reviewed to determine eligibility for payment– If services are considered incidental, mutually exclusive,integral to the primary service rendered, or part of a globalallowance, they are not eligible for separate reimbursement.27
COB collection form All Blue Plans have placed COB questionnaires on local Websites, where they can be accessed, printed and presented tomembers believed to have COB. Members believed to have other coverage should be given acopy of the questionnaire for completion. Providers can download and print a copy of the COBquestionnaire by accessing the Links section on Blue e or onour Web site bcbsnc.com.SM The mailing address for the member’s plan can be found on theback of their member ID card, or by calling the customerservice number also listed on the back of the card.28
Medicare Advantage private fee for service MA PFFS is a health plan offered by an organization that paysphysicians and providers on a fee-for-service basis. Patients can obtain services from any licensed physician orprovider in the United States who is qualified to be paid byMedicare and accepts the health plan’s terms and conditions ofpayment. There is usually no contract or network that providers sign upfor to provide service to PFFS patients. The Plan must provide the same coverage under PFFS asMedicare Part-A and Part-B, and may also offer additionalbenefits.29
Medicare Advantage private fee for service Unlike coordinated care health plans, the MA PFFS plansare not required to contract with providers to participate. Providers need to know that the member is covered undera PFFS health plan, accept the health plan’s terms andconditions and provide care to be able to bill for services. PFFS plans call these providers “deemed providers.” If a provider does not agree to the terms and conditions,the provider should not provide services to the PFFSmember (does not apply to emergency care situations).30
Medicare Advantage private fee for service Ask the member for his or her ID card. Members will nothave a standard Medicare card; instead, a Blue logo willbe visible on the ID card along with the following logo: Use the same processes you use today to verify eligibilityby calling 1-800-676-Blue (2583) and providing the alphaprefix or electronically with Blue eSM31
Medicare Advantage private fee for service Instructions for accessing PFFS terms and conditions are onthe back of the member’s ID card. Terms and conditions are posted on the Web site of themember’s Plan. Terms and conditions for any Blue MA PFFS product can alsobe accessed through BCBSNC’s Web site atbcbsnc.com/providers/edi/– To view the terms and conditions for any MA PFFS member’s Blue healthplan, from our Web site, enter the first three letters of the member’sidentification number as listed on the member’s ID card and click “Go.”Your browser will then be directed to the appropriate terms and conditionsfor that member.32
Medicare Advantage private fee for service Submit claims to BCBSNC Do not bill Medicare directly for any services rendered to a MAmember. Payment will be made directly by BCBSNC. Reimbursements are the equivalent of the current Medicarepayment amount for all covered services (i.e., the amount youwould collect if the member was enrolled in original Medicare).¾ Details are provided in the product terms and conditions. Providers can collect any applicable cost-sharing amount (i.e.,co-pay, deductible).33
Add title for transition slideImproving member’s health34
Online member services BCBSNC provides online services for members, includingaccess to exclusive features designed to promote betterhealth. BCBSNC members can register or log in to our MemberServices site bcbsnc.com/memberservices to accesstheir account information or take part in programsdesigned to encourage healthy living and reward physicalactivity.Available member options include: Find a doctor Get details of their health plan Check claims 24/735
Spanish speaking patientsbcbsnc.com/azul/Spanish-speaking customer service1-877-258-333436
Finding an interpreter In North Carolina, providers can locate an interpreter toassist in communicating with Spanish-speaking and otherforeign language-speaking patients through CATI(Carolina Association of Translators and Interpreters). CATI is an association of working translators andinterpreters in North Carolina & South Carolina and is achapter of the American Translators Association. CATI provides contact information of translators andinterpreters within North Carolina atwww.catiweb.org/index.htm.37
Universal Preventive Reminder Customized services – only if member is overdue for screening,per claims:–––––––Colon cancerBreast cancerCervical cancerCholesterolDiabetesPneumococcal vaccine – 65 Vision screening – 65 General services:– Flu shot– Blood pressure38
Provider Toolkits Preventive Health Topics: Adult Obesity Childhood Obesity Tobacco Cessation (including Spanish materials) Stress Management Screening Topics: Chlamydia Screening Colorectal Cancer Screening Depression Screening Mammography ScreeningToolkit contents include assessment tools, clinical guidelines, and patienteducation materials and worksheets.39
Results - Toolkit volumesNumber of Toolkits Distributed by 072008From 2005-2008, Toolkit orders almost tripled!!40
Provider Toolkit Changes Provider Satisfaction Survey indicated over half ofproviders were more likely to use the toolkit materials ifthey were offered online Downloadable contents available online– Patient education materials Some items available for order– Assessment tools, posterswww.bcbsnc.com/providers/toolkit41
Benefits for Nutrition Counseling Nutrition counseling is a covered benefit for BCBSNC members. Nutrition counseling is available for both adults and children. Through nutrition counseling your patients can get help with weightloss, eating healthy and becoming more physically active. The nutrition counseling benefit is available to commercial members(Blue Options and Blue Advantage) actively enrolled in our MemberHealth Partnerships (MHP) program. Members can enroll in MHP by calling 1-800-218-5295. When members enroll in MHP, they receive up to six nutritioncounseling visits per year with copays waived if they go to acredentialed, licensed registered dietitian in an office-based setting.42
How to find a network dietitian1. Enter zip code orcounty2. Select “Nutrition”in specialtyfield3. Click on Find aDoctor Now43
Tobacco Cessation Counseling Codes Choice of code depends on time spent with the patient. These codeswill be reimbursed in addition to other E & M services provided on thesame day.CodeTime spent with patient99406Intermediate visit3-10 minutes99407Intensive visit10 or more minutesSince 2005, tobacco cessation counseling has more than quadrupled!44
Add title for transition slidePharmacy and medication45
Medication Dedication / 90 days supply Medication Dedication is the BCBSNC medication adherenceprogram. We are targeting the conditions of high blood pressure, highcholesterol, congestive heart failure and diabetes. Our goal isto improve member health through improved medicationadherence. Providers are encouraged to write 90 day scripts wheneverpossible. Program includes generic copay waiver through 12/31/09, fordrugs used to treat the four targeted conditions.46
Drugs being added to Prior Review list as ofJuly 1, 2009 Effective July 1, 2009, prior review is required for coverage ofalefacept injection (Amevive) and for transmucosal fentanyl (Actiq,Fentora). In order to request coverage for Amevive or for transmucosal fentanyl,providers must complete and fax the appropriate prior review fax formthat can be downloaded from our Web site at bcbsnc.com. Criteria for coverage of Amevive are outlined in a new medical policythat is available online in the “Medical Policy” section. The criteria for coverage of transmucosal fentanyl follows FDAapproved indications.47
Self administered medications BCBSNC’s pharmacy and medical staff reviews all medicationson a periodic basis to determine if any medications can besafely administered by a member as self administered. When safe for self administration, medications are coveredunder the member’s pharmacy benefit rather than themember’s medical benefit. As of January 1, 2009, thirty-nine additional drugs have beenadded to the list of self administered medications.48
Reclassified as self administered effectiveJanuary 1, 2009 Injectables– Antagon – Apokyn – Bravelle – Chorionic Gonadotropin – Cetrotide –Cimzia – Follistim/AQ – Fuzeon – Ganirelix – Gonal – Luveris – Menopur– Novarel – Ovidrel – Pregnyl – Repronex – Somatuline – Zorbtive Oral– Copegus – Exjade – Gleevec – Kuvan – Nexavar – Orfadin – Rebetol –Revlimid – Ribasphere – Ribavirin – Sensipar – Sprycel – Sutent –Tarceva – Temodar – Thalomid – Tykerb – Xeloda 150mg – Xeloda500mg Inhaled– Tobi – Pulmozyme49
Electronic prescribing (ePrescribing) is an efficient, economicaland secure way of using health care technology (e.g.,computers or personal digital assistants) to improveprescription accuracy and patient safety, while increasing theuse of more cost effective drugs by providing patient specificdrug information at the point of care.– ePrescribers electronically and securely incorporate patient medicalinformation with health plan formulary, patient eligibility and medicationhistory at the point of care.–– The result is a safe and efficient process with more accurate medicationorders being electronically sent to
Provider Appeal for medical necessity or billing disputes. Level II Provider Appeals are conducted by an Independent Review Organization, and there is a filing fee associated with all requests for a Level II Post-Service Provider Appeal. Re
