Office Manual. Professional Provider

Transcription

1 Professional Provider Office Manual Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 23XX6767 R08/09

2 Blue Cross and Blue Shield of Louisiana PROFESSIONAL PROVIDER NETWORK This manual is designed to provide information you will need as a participant in the Blue Cross and Blue Shield of Louisiana Professional Provider Network. To use your manual, first familiarize yourself with the Network Overview and Definitions sections. From that point on, the Table of Contents should direct you to the information you need. Periodically, we send newsletters and informational notices to providers. Please keep this information and a copy of your respective provider agreement(s) along with your manual for your reference. Provider newsletters can be found on the Provider page of our website at under Provider News. If you have questions about the information in your manual or your participation as a network provider, please call Network Administration at (800) , option 1 or (225) CPT only copyright 2008 American Medical Association. All rights reserved. ICD Ingenix, Inc. HCPCS Practice Management Information Corporation Note: This manual contains a general description of Benefits that are available subject to the terms of a Subscriber s contract and our corporate medical policies. The Subscriber Contract/Certificate contains information on Benefits, limitations and exclusions and managed care benefit requirements. It also may limit the number of days, visits or dollar amounts to be reimbursed. This manual is provided for informational purposes only. Every effort has been made to print accurate, current information. Errors or omissions, if any, are inadvertent Rev 2:1 August 1

3 Table of Contents Quick Reference Guide to Important Addresses and Phone Numbers 4 Section 1: Blue Cross and Blue Shield of Louisiana Network Participation 5 Introduction 5 Participating Provider Agreements 5 Allied Health Providers 6 Nonparticipating Providers 6 Credentialing Program 7 Provider Availability Standards 8 Blue Cross Provider Directories 9 Provider Update Request Form 10 Section 2: Blue Cross Network Overview 12 Network Overview 12 BlueCard Program 15 RxBLUE/Medicare Part D Program 17 Medicare Advantage 18 Medicare Advantage PPO 18 Medicare Advantage PFFS 19 Section 3: Claims Submission 20 Filing Claims 20 Timely Filing and Refunds Process 20 Procedure and Diagnosis Codes and Guidelines 20 Overpayments 21 National Provider Number (NPI) 21 Modifiers 22 Modifier Guidelines 22 Billing Modifier Billing Modifier Billing for Surgical Assistant Services 24 Unlisted Codes 24 Radiology, Pathology and Laboratory 24 Multiple Surgical Procedures 24 Equipment, Devices and Supplies 25 Code Editing: Billing Practices Subject to Reduction 25 Provider Access to ilinkblue Medical Coding Section 25 Sample CMS-1500 Health Insurance Claim Form Health Insurance Claim Form Explanation Claim Form Filing Guidelines 29 Sample UB-04 Claim Form 30 UB-04 Claim Form Explanation 31 Electronic Data Interchange 34 Electronic Funds Transfer Application 36 Coordination of Benefits (COB) 37 Subrogation 37 Medicare Supplemental Claims 38 Section 4: Billing Guidelines 39 Ambulance 39 Anesthesia 40 Autism 44 Behavioral Health 45 Dialysis 46 Durable Medical Equipment 47 Sample DME Certification Form 49 Home Health Agency 50 2 Professional Provider Office Manual

4 Table of Contents Home Health Agency Revenue Codes 50 Infusion Therapy 53 Laboratory - Using Participating Labs 54 List of Participating Labs 55 Sleep Study 56 Urgent Care/After Hours Centers 57 Section 5: Reimbursement 58 Allowable Charges 58 Member Cost-Sharing 58 Reimbursement Review 58 Sample Reimbursement Review Form 59 Sample Weekly Provider Payment Register (Legacy) 60 Legacy Provider Payment Register Explanation 61 Facets Payment Registers 62 Sample Weekly Provider Payment Register (Facets) 63 Facets Payment Register Explanation 64 Section 6: Consumer Directed Health Care 65 Consumer Directed Health Care 65 Consumer Directed Health Plans 65 Section 7: FEP Benefit Information 67 Standard Option 67 Basic Option 67 Additional FEP Benefit Information 68 Section 8: Medical Management 69 Overview 69 MNRO 69 Authorization Process 69 Concurrent Review 70 Case Management 71 Retrospective Review 71 Medical Policy Inquiry 71 Direct Access 72 Services Requiring Authorization 73 Authorization for High-tech Imaging Services 75 Medical Records Adult and Pediatric Ambulatory Medical Review Definition of Guidelines Section 9: General Dispute Resolution & Arbitration Process 77 Section 10: Appeals 78 Section 11: Preventive Medicine Guidelines 84 Section 12: Communicating with Blue Cross 90 Electronic Benefit Verification 90 Provider Services Voice Response Telephone System Call Center 90 Customer Service 91 Preadmission Authorization 91 Provider Network Administration 91 Provider Relations Services 91 Section 13: Definitions Rev 2:1 August 3

5 Quick Reference Guide to Important Addresses and Phone Numbers Provider Services Voice Response Telephone System (Call Center) (800) Option 1 - Fax or voice summary of benefits or claim status Option 2 - Calling to set up a new authorization Option 3 - Out-of-state policy Option 4 - Federal Employee Policy (FEP) Option 5 - All other calls - Network Administration Provider Network Administration network.administration@bcbsla.com Participation/Contracting/Credentialing Questions: (800) or (225) Provider Relations: (225) Claims Addresses All completed claim forms should be forwarded to the following addresses for processing: Blue Cross and Blue Shield of Louisiana P. O. Box Baton Rouge, LA FEP claims should be mailed to: Blue Cross and Blue Shield of Louisiana FEP Claims P. O. Box Baton Rouge, LA Electronic Services ilinkblue.providerinfo@bcbsla.com (800) 216-BLUE (2583) (225) 293-LINK (5465) Appeals and Grievances/Provider Dispute Resolution Blue Cross and Blue Shield of Louisiana Appeals and Grievance Department P. O. Box Baton Rouge, LA (800) or (225) Fax (225) BlueCard Eligibility Line (800) 676-BLUE (2583) Member Benefits Call the number on the member s ID card. Fraud & Abuse Hotline (800) EDI Clearinghouse EDICH@bcbsla.com (225) Federal Employee Program (FEP) (800) TRICARE (800) Professional Provider Office Manual

6 Section 1: Blue Cross and Blue Shield of Louisiana Network Participation Participating providers are those physicians and allied health providers who have entered into a provider agreement with Blue Cross and Blue Shield of Louisiana (Blue Cross). As a participating provider in our Key Physician, Preferred Care PPO and/or Advantage Blue Networks, you join other providers linked together through a business relationship with Blue Cross. Our networks emphasize the primary roles of the participating provider and Blue Cross and Blue Shield. They are designed to create a more effective business relationship among providers, consumers and Blue Cross and Blue Shield. Our participating provider networks: Facilitate providers and Blue Cross working together to voluntarily respond to public concern over costs Continue to give Blue Cross and Blue Shield subscribers freedom to choose their own providers Demonstrate providers support of realistic cost-containment initiatives Limit out-of-pocket expenses for patients to predictable levels and reduce their anxiety over the cost of medical treatment Participating Provider Agreements Your responsibilities and agreements as a participating provider are defined in your provider agreement(s). You should always refer to your agreement when you have a question about your network participation. As a participating provider, you are responsible for: Submitting claims for Blue Cross and Blue Shield subscribers This includes claims for inpatient, outpatient and office services. To ensure prompt and accurate payment, it is important that you provide all patient information on the CMS-1500 claim form (or the UB-04 claim form for certain allied providers) including appropriate Physicians Current Procedural Terminology (CPT ) codes and ICD-9-CM diagnosis codes. As of May 23, 2008, National Provider Identifiers (NPIs) are required on all claims (Blue Cross-assigned provider numbers will no longer be used). The Claims Submission section of this manual gives specific information about completing the claim form as well as CPT and ICD-9-CM coding information. The Allied Health Providers section gives specific information about completing the CMS-1500 and UB-04 claim forms. Accepting Blue Cross payment plus the subscriber s deductible, coinsurance and/or copayment, if applicable, as payment in full for covered services Blue Cross payment for covered services is based on your charge not to exceed Blue Cross allowable charge. You may bill the subscriber for any deductible, coinsurance, copayment and/or noncovered service. However, you agree not to collect from the subscriber any amount over Blue Cross allowable charge. The Provider Payment Register summarizes each claim and itemizes patient liability, the amount above the allowable charge and other payment information. Additional information concerning the payment register is included in the Reimbursement section of this manual. Cooperating in Blue Cross cost-containment programs where specified in the Subscriber Contract/Certificate and not billing the subscriber or Plan for any services determined to be not Medically Necessary, unless the provider has notified the subscriber in advance in writing that certain not medically necessary services will be the subscriber s responsibility. Generic or all-encompassing notifications will not be deemed to meet the specific notification requirement mentioned above. Certain Plan Subscriber Contracts/Certificates include cost-containment programs such as prior authorization, concurrent review and case management. The subscriber s identification card will contain telephone numbers for prior authorization. Also, the subscriber should inform you if his/her benefit program includes cost-containment provisions or incentives. CPT only copyright 2008 American Medical Association. All rights reserved Rev 2:1 August 5

7 Allied Health Providers Allied health providers are licensed and/or certified healthcare providers other than a physician, or hospital, and may include a clinical laboratory, urgent care center, managed mental healthcare provider, optometrist, chiropractor, podiatrist, psychologist, therapist, durable medical equipment supplier, ambulatory surgical center, diagnostic center and any other healthcare provider, organization, institution or such other arrangement as recognized by Blue Cross. Nonparticipating Providers Nonparticipating providers are providers who have not signed a contract to participate in any Blue Cross network. Blue Cross establishes an allowable charge for covered services provided by nonparticipating providers that is based on the negotiated fee that has been accepted by most participating providers. When a member uses a nonparticipating provider, this allowable charge is used to determine Blue Cross payment for a member s medically necessary covered services and the amount the member must pay. The member may pay significant costs when he uses a nonparticipating provider. This is because the amount that some providers charge for covered services may be higher than the negotiated fees that are accepted by most providers. Also, participating providers waive the difference between the actual billed charge and the allowable charge, while nonparticipating providers will not. We ask that you inform patients of your billed charges before providing services as a nonparticipating provider. The member has the right to file an appeal to receive benefits based on a higher allowable charge, if the member received covered services from a nonparticipating provider who was the only provider available to deliver the covered service within a 75 mile radius of the member s home or if the covered service that the member received from the nonparticipating provider was an emergency medical service. When a member receives covered services from a nonparticipating hospital, the benefits that Blue Cross will pay under the member s benefit plan will be reduced by 30 percent. If covered services are received from a nonparticipating hospital because these services were not available from a participating hospital, Blue Cross will not apply the 30 percent reduction in benefits. If emergency medical services are received from a nonparticipating hospital, the company will not apply the 30 percent reduction in benefits. HMO Louisiana, Inc. Members HMO Louisiana, Inc. (HMOLA) members have no benefits for services provided by nonparticipating providers without obtaining prior approval. When we both (1) issue an authorization that the services are Medically Necessary, and (2) approve a member to receive the medically necessary covered services from a nonparticipating provider, benefits will be as follows: The allowable charge is the lesser of the provider s billed charge or an amount we have negotiated with the provider as payment in full for the member s covered services. This amount is the nonparticipating provider s allowable charge and it is used to determine the amount that we pay for the member s covered services. An HMOLA member does not have to obtain prior authorization to receive emergency medical services. A member should seek emergency care at the nearest facility. In this case, the allowable charge is the lesser of the provider s billed charge or an amount we have negotiated with the provider as payment in full for the member s covered services. This amount is the nonparticipating provider s allowable charge and it is used to determine the amount that we will pay for the member s covered services. 6 Professional Provider Office Manual

8 Credentialing Program Participating providers are expected to cooperate with quality-of-care policies and procedures. An integral component of quality of care is the credentialing of participating providers. This process consists of two parts: credentialing and recredentialing. Credentialing Process Credentialing consists of an initial full review of a provider s credentials at the time of application to our networks. 1) If a provider applies for participation in any of our networks, he/she must be credentialed before being approved for participation. A Louisiana Standardized Credentialing Application (LSCA) and provider agreement are forwarded to the provider upon receipt of his/her request for participation in our networks. This form can be found on our website under Forms for Providers. 2) The form and agreement are completed by the provider and submitted to Blue Cross for approval. 3) Upon receipt of the completed LSCA, credentialing staff verify the provider s credentials including, but not limited to, state license, professional malpractice liability insurance, State CDS Certificate, etc., according to the Plan s policies and procedures and Utilization Review Accreditation Committee (URAC) standards. 4) Blue Cross staff and the Credentialing Subcommittee, review the provider s credentials to ascertain compliance with the following credentials criteria. All participating providers must maintain this criteria on an ongoing basis: Unrestricted license to practice medicine in Louisiana as required by state law Agreement to participate in the Blue Cross networks. Professional liability insurance that meets required amounts Malpractice claims history that is not suggestive of a significant quality of care problem Appropriate coverage/access provided when unavailable on holidays, nights, weekends and other off hours Absence of patterns of behavior to suggest quality of care concerns Utilization review pattern consistent with peers and congruent with needs of managed care No sanctions by either Medicaid or Medicare No disciplinary actions No convictions of a felony or instances where a provider committed acts of moral turpitude No current drug or alcohol abuse 5) Based upon compliance with the criteria, Blue Cross staff will recommend to the Credentialing Subcommittee that a provider be approved or denied participation in our networks. 6) The Credentialing Subcommittee, comprised of network practitioners, will make a final recommendation of approval or denial of a provider s application. Recredentialing After a provider has completed the initial credentialing process, he/she will undergo recredentialing at least every three years thereafter from the date of the last approval. The recredentialing process is conducted in the same manner as outlined in the Credentialing section above. The provider is considered to be approved by the Credentialing Subcommittee and recredentialed for another three-year cycle unless otherwise notified. Status Changes A provider is required to report changes to his/her credentialing criteria to Blue Cross within 30 days from the date of occurrence. Failure to do so may result in immediate termination. CLIA Certification Required If you perform laboratory testing procedures in your office, we require that a copy of your Clinical Laboratory Improvement Act (CLIA) certification be provided along with your Louisiana Standardized Credentialing Application when applying for credentialing or recredentialing with Blue Cross. If you have CLIA certification, please fax or mail us a copy of your certification: BCBSLA - Network Operations P.O. Box Baton Rouge, LA Fax: (225) Attn: Network Operations 2009 Rev 2:1 August 7

9 Provider Availability Standards Blue Cross is committed to providing high quality healthcare to all members, promoting healthier lifestyles and ensuring member satisfaction with the delivery of care. Within this context and with input and approval from various network providers who serve on our Medical Quality Management Committee, we developed the following Provider Availability Standards and Acute Care Hospital Availability Standards. TYPE ACCESS STANDARD EXAMPLES Emergency Medical situations in which a member would reasonably believe his/her life to be in danger, or that permanent disability might result if the condition is not treated Immediate access, 24 hours a day, 7 days a week Loss of consciousness Seizures Chest pain Severe bleeding Trauma Urgent Medical conditions that could result in serious injury or disability if medical attention is not received Routine Primary Care Problems that could develop if untreated but do not substantially restrict a member s normal activity 30 hours or less Severe or acute pain High fever in relation to age and condition 5 to 14 days Backache Suspicious mole Preventive Care Routine exams 6 weeks or less Routine physical Well baby exam Annual Pap smear Additional Availability Standards Network physicians are responsible for assuring access to services 24 hours a day, 365 days a year other than in an emergency room for non-emergent conditions. This includes arrangements to assure patient awareness and access after hours to another participating physician. All network providers must offer services during normal working hours, typically between 9 a.m. and 5 p.m. Average office waiting times should be no more than 30 minutes for patients who arrive on time for a scheduled appointment. The physician s office should return a patient s call within four to six hours for an urgent/acute medical question and within 24 hours for a non-urgent issue. Acute Care Hospital Availability Standards Acute care hospitals are responsible for assuring access to services 24 hours a day, 365 days a year. All contracted hospitals must maintain emergency room or urgent care services on a 24-hour basis and must offer outpatient services during regular business hours, if applicable. 8 Professional Provider Office Manual

10 Blue Cross and Blue Shield of Louisiana Provider Directories As a participating provider, your name is included in the Blue Cross product-specific provider directories, which are distributed to all subscribers and featured at our website, Participating providers are listed in the directories by parish in alphabetical order under their specialty(ies). Thousands of healthcare professionals and facilities across the state are in our networks. You can find the one you need quickly with our easily searchable directory. Listings are updated daily. We make every effort to ensure the information in our provider directories is current and accurate. If new providers join your practice, if providers in your clinic retire or move or if you close/merge a practice, please notify Provider Network Administration in writing. A Provider Update Request Form is provided in this manual and can be used to notify us of changes or additions to provider directories. You may also complete the update form online at under Provider, Forms for Providers. Select the Provider Update Form form from the list and fill in the blanks. You may notify us of a change by contacting us through the following ways as well: Phone: (800) , option 3 Network.Administration@bcbsla.com Fax: (225) Please note: Blue Cross cannot guarantee the continuing participation of providers listed in the online directories. Providers with multiple locations may not participate at all locations. Facility-based physicians may not be contracted healthcare providers Rev 2:1 August 9

11 PROVIDER UPDATE REQUEST FORM Use this form to give Blue Cross and Blue Shield of Louisiana the most current information on your practice. Updates may include tax identification number changes, address changes, etc. Please type or print legibly in black ink. If you need more space, attach additional sheets and reference the question(s) being answered. GENERAL INFORMATION Provider s Last Name First Name Middle Clinic Name Tax ID Number Clinic s National Provider Identifier (NPI) Office Hours Age Range Provider s National Provider Identifier (NPI) Name of Individual Completing This Form Phone Number Fax Number BILLING ADDRESS (address for payment registers, reimbursement checks, etc.) Former Billing Address City, State and Zip Code Phone Number New Billing Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change MEDICAL RECORDS ADDRESS (address for medical records request) Former Medical Records Address City, State and Zip Code Phone Number New Medical Records Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change CORRESPONDENCE ADDRESS CHANGE (address for manuals, newsletters, etc.) Former Correspondence Address City, State and Zip Code Phone Number New Correspondence Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change 23XX7231 R05/08 Blue Cross and Blue Shield of Louisiana Incorporated as Louisiana Health Service & Indemnity Company 10 Professional Provider Office Manual

12 PHYSICAL ADDRESS CHANGE Former Physical Address City, State and Zip Code Phone Number New Physical Address City, State and Zip Code Phone Number Fax Number Address Effective Date of Address Change TAX IDENTIFICATION NUMBER CHANGE Former Clinic/Group Name Former Tax ID Number Through Date of Former Tax ID Number New Clinic/Group Name New Tax ID Number Effective Date of New Tax ID Number Please attach a copy of your new IRS Employer Identification Number Letter NETWORK TERMINATION Terminated Network Effective Date Provider Number Tax ID Number Reason for Termination NETWORK TERMINATION (all networks) Terminated Address City, State and Zip Code Phone Number Provider Number Tax ID Number Reason for Termination Effective Date Please return this form to: Attn: Network Operations Blue Cross and Blue Shield of Louisiana P.O. Box Baton Rouge, LA (225) (fax) If you have any questions about this form, please call Network Operations at: (800) , Option 3 (225) (Baton Rouge Area) 23XX7231 R05/ Rev 2:1 August Blue Cross and Blue Shield of Louisiana Incorporated as Louisiana Health Service & Indemnity Company 11

13 Section 2: Blue Cross and Blue Shield of Louisiana Network Overview For 75 years, Blue Cross has worked to develop business relationships with doctors, hospitals and other healthcare providers throughout Louisiana. These relationships have allowed us to develop the largest, most comprehensive provider networks in the state. With the number of insurance companies and network programs available, it can be quite challenging for providers to navigate the various administrative requirements of these programs. To help you better understand the Blue Cross networks in which you may participate, we are providing an overview of our provider network programs. In an effort to increase efficiency, reduce administrative costs and maintain Blue Cross and Blue Shield brand compliance, Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. (HMOLA) began issuing new and improved member ID cards on November 5, While the cards have a new look, all of the key information will remain the same. We have included samples of the new Blue Cross and HMOLA cards below for you and your staff to reference. Because it will take up to two years for all members to receive an upgraded card, we ask that you continue to accept both old and new formats during the transition period. If you have any questions about Blue Cross ID card changes, please call Provider Services at (800) Preferred Care PPO Our Preferred Care PPO network includes hospitals, physicians and allied providers. Members with PPO benefit plans receive the highest level of benefits when they receive services from PPO providers Providers participating in the Preferred Care PPO Network have signed a special agreement and agreed to an allowable charge different from the allowable charge paid when treating a Traditional Managed Indemnity subscriber. A special Preferred Care logo distinguishes Preferred Care PPO subscribers from our other subscribers. This logo is located at the top right corner of the ID card as shown. The PPO in a suitcase logo identifies the nationwide BlueCard Program. PPO members are issued ID cards in the member s name only. Cards are not produced for covered spouses or dependents. Covered spouses and/or dependents may use the ID card in the member s name when accessing services. This ID card is used for both medical and dental coverage. Important Note: While you will see references to the Blue Cross and Blue Shield of Louisiana Traditional/Key and Advantage Blue Point of Service (POS) networks in this manual, these products have not been marketed in more than a year and the majority of these members have been moved to our Preferred Care PPO product or, where applicable, an HMOLA based product. 12 Professional Provider Office Manual

14 HMO Louisiana, Inc. HMO Louisiana, Inc. (HMOLA) is a wholly owned subsidiary of Blue Cross and Blue Shield of Louisiana. The HMOLA provider network is a select group of physicians, hospitals and allied providers who provide services to individuals and employer groups seeking managed care benefit plans. HMOLA is available in the Baton Rouge, New Orleans, and Shreveport service areas. HMOLA allows members to choose from both HMO and Point of Service (POS) benefit plans. Members pay a lower copayment when they receive services from PCPs. HMOLA members carry an ID card similar to the one shown here. Please note: HMOLA providers should follow the guidelines set forth in this manual. Differences and additional guidelines can be found in the HMOLA Provider Office Manual, which is a supplement to this office manual. HMO members are issued ID cards for each covered member and separate ID cards are issued for each covered dental member. The ID number is the same for both ID cards. Traditional/Key Managed Indemnity This is our core network of Hospitals, Physicians and Participating Allied Providers. Providers who participate in this network agree to accept the negotiated reimbursement amount (allowable charge) as payment-in-full for covered services and agree not to collect any amount above the allowable charge from our members. All Blue Cross participating providers agree to file claims for Blue Cross and Blue Shield (BCBS) members and cooperate in cost-containment programs such as prior authorization, concurrent review and case management. Our Traditional/Key members carry ID cards with the traditional Blue Cross logo as shown. Please Note: This product is no longer sold and upon renewal date, groups will be moved to another product/network. Advantage Blue POS Our Advantage Blue Point of Service (POS) includes: Allied Providers Hospitals Primary Care Physicians (PCPs) specializing in: family practice obstetrics/gynecology general practice pediatrics internal medicine Referral Specialists (representing all medical specialties) The Advantage Blue POS program encourages members to obtain services from a PCP for their healthcare needs. When members follow the guidelines of this program, they receive the highest level of benefits. However, they may seek care from a non-network provider at a greater cost to themselves. Subscribers with Advantage Blue POS carry the ID card above. Please Note: This product is no longer sold and upon renewal date, groups will be moved to another product/network. Advantage Blue POS members are issued ID cards for each covered member and separate ID cards are issued for each covered dental member. The ID number is the same for both ID cards Rev 2:1 August 13

15 Federal Employee Program The Federal Employee Program (FEP) provides benefits to federal employees and their dependents. These members access the Preferred Care PPO Network. FEP members have two benefit plans from which they may choose: Standard Option and Basic Option. Under Standard Option, members receive the highest level of benefits when they receive care from in-network providers and reduced benefits when they receive care from out-of-network providers. Members with Basic Option receive no benefits when they receive care from out-of-network providers except for select situations such as emergency care. For more information on FEP benefits, please see the Benefit Information section of this manual. BlueChoice 65 BlueChoice 65 is a series of Medicare supplement plans. It is designed to pay for many of the expenses Medicare doesn t pay. Some of the options in this series include: Part A deductible coverage Part B deductible coverage, coinsurance and excess charges Skilled nursing coinsurance BlueChoice 65 BlueChoice 65 Select plans feature lower premiums and a select network of hospitals that have agreed to waive the Part A deductible and coinsurance. Please note: BlueChoice 65 refers to certain contracts and is not connected with or endorsed by the U.S. government or the federal Medicare program. BlueChoice 65 Select 14 Professional Provider Office Manual

16 BlueCard Program The BlueCard Program links participating providers and the independent Blue Cross and Blue Shield (BCBS) Plans across the country and abroad with a single electronic network for professional, outpatient and inpatient claims processing and reimbursement. The program allows BCBS participating providers in every state to submit claims for patients who are enrolled through another Blues Plan to their local BCBS Plan. You should submit claims for BCBS members (including Blue Cross only and Blue Shield only) visiting you from other areas directly to Blue Cross and Blue Shield of Louisiana. Blue Cross and Blue Shield of Louisiana is your sole contact for all BCBS claims submissions, payments, adjustments, services and inquiries. How to Identify BlueCard Members When out-of-area BCBS members arrive at your office or facility, be sure to ask them for their current membership ID card. The two main identifiers for BlueCard members are the alpha prefix and a suitcase logo. Alpha Prefix The three-character alpha prefix of the member s identification number is the key element used to identify and correctly route out-of-area claims. The alpha prefix identifies the Blue Plan or the national account to which the member belongs. There are three types of alpha prefixes: plan-specific, account-specific and international: 1) Plan-specific alpha prefixes are assigned to every BCBS Plan and start with X, Y, Z or Q. The first two positions indicate the Plan to which the member belongs while the third position identifies the product in which the member is enrolled. 2) Account-specific prefixes are assigned to centrally-processed national accounts. National accounts are employer groups with offices or branches in more than one area, but offer uniform coverage benefits to all of their employees. Account-specific alpha prefixes start with letters other than X, Y, Z or Q. Typically, a national account alpha prefix will relate to the name of the group. All three positions are used to identify the national account. 3) Occasionally, you may see ID cards from foreign BCBS members. These ID cards will also contain three-character alpha prefixes. For example, JIS indicates a Blue Cross and Blue Shield of Israel member. The BlueCard claims process for international members is the same as that for domestic BCBS members. ID cards with no Alpha Prefix Some ID cards may not have an alpha prefix. This may indicate that the claims are handled outside the BlueCard Program. Please look for instructions or a telephone number on the back of the member s ID card for information on how to file these claims. If that information is not available, call Provider Services at (800) Suitcase Logo BlueCard Traditional is a national program that offers members traveling or living outside of their Blue Plan s area the traditional or indemnity level of benefits when they obtain services from a provider or hospital outside of their Blue Plan s service area. Members are identified by the empty suitcase logo on their ID card. BlueCard PPO offers members traveling or living outside of their Blue Plan s area the PPO level of benefits when they obtain services from a provider or hospital designated as a BlueCard PPO provider. Members are identified by the PPO in a suitcase logo on their ID card. HMO patients serviced through the BlueCard Program In some cases, you may see BCBS HMO members affiliated with other BCBS Plans seeking care at your office or facility. You should handle claims for these members the same way you handle claims for Blue Cross and Blue Shield of Louisiana members and BCBS Traditional and PPO patients from other Blue Plans by submitting them through the BlueCard Program. Members are identified by the empty suitcase logo on their ID card. BlueCard members throughout the country have access to information about participating providers through BlueCard Access, a nationwide toll-free number (800) 810-BLUE [2583]) that allows Blue Cross and Blue Shield of Louisiana to direct patients to them. Members call this number to find out about BlueCard providers in another Blue Plan s service area. You can also use this number to get information on participating providers in another Blue Plan s service area Rev 2:1 August 15

17 How the Program Works 1) You may verify the patient s coverage by calling BlueCard Eligibility at (800) 676-BLUE (2583). An operator will ask you for the alpha prefix on the member s ID card and will connect you to the appropriate membership and coverage unit at the member s plan. If you are unable to locate an alpha prefix on the member s ID card, check for a phone number on the back of the ID card, and if that s not available, call Provider Services at (800) ) After you render services to a BCBS subscriber, you should file the claim (according to your contractual arrangements) with Blue Cross and Blue Shield of Louisiana. Reminder: The claim must be filed using the three-character alpha prefix and identification number located on the patient s ID card. 3) Once the claim is received, Blue Cross and Blue Shield of Louisiana electronically routes it to the subscriber s own independent BCBS Plan. 4) The subscriber s plan adjudicates the claim and transmits it to Blue Cross and Blue Shield of Louisiana, either approving or denying payment. The processing time of the claim may take longer than most Blue Cross processes. 5) Blue Cross and Blue Shield of Louisiana reconciles payment and forwards it to you according to your payment cycle. 6) The subscriber s local Blue Plan sends a detailed Explanation of Benefits (EOB) report to the subscriber. Types of claims filed through the program All professional claims as well as facility inpatient and outpatient claims for BCBS out-of-state subscribers should be filed to Blue Cross and Blue Shield of Louisiana. Medicare Primary could be paid differently by each Blue plan. Blue Cross and Blue Shield of Louisiana pays according to the member s participation with us and their participation with Medicare. If the member is of Medicare age and does not indicate that Medicare is primary, we will pay as if Blue Cross is primary. The Federal Employee Program (FEP) and other Blue Cross plans will pay according to the member s contract language. However, if it is determined that the member should have been set up initially with Medicare as primary, the provider will be asked to return any reimbursement and the claim will have to be reprocessed with Medicare as primary. BlueCard Claims Submission Submit claims to: Blue Cross and Blue Shield of Louisiana P. O. Box Baton Rouge, LA If you contract directly with the member s BCBS Plan, you should file the claim directly to the member s Plan. When calling to authorize an admission or other services, you should continue to call the telephone numbers listed on the subscriber s ID card. Members with Consumer Directed Health Plans Like BlueSaver Many consumer directed healthcare (CDHC) members carry healthcare debit cards that allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). Some cards are "stand-alone" debit cards that cover out-of pocket costs, while others also serve as a member identification card and include the member's identification number. The combined card will have a nationally recognized Blue logo, along with the logo from a major debit card company such as MasterCard or Visa. Members can use their cards to pay outstanding balances on billing statements. If your office currently accepts credit card payments, there is no additional equipment necessary. The cost to you is the same as the current cost you pay to swipe any other signature debit cards. If the member presents a debit card (stand-alone or combined), be sure to verify the member's cost sharing amount before processing payment. Do not use the card to process full payment up front. For more information, see the Consumer Directed Health Plans section of this manual. Please Note: If you have questions about the healthcare debit card processing instructions or payment issues, please contact the toll-free debit card administrator's number of the back of the card. 16 Professional Provider Office Manual

18 RxBLUE: Our Medicare Part D Plan Blue Cross and Blue Shield of Louisiana offers a Medicare Part D prescription drug program called RxBLUE. RxBLUE benefits include a multi-tiered open drug formulary including a select list of generic drugs that can be obtained for $0 co-pay. Providers can view the RxBLUE formulary online at the special RxBLUE page of Additionally, RxBLUE is available through epocrates at and to those physicians who are using the Pocketscrips eprescribing software. For more information about Medicare Part D, visit the Centers for Medicare and Medicaid Services (CMS) website at or call RxBLUE customer service at (888) Rev 2:1 August 17

19 Medicare Advantage Members From Other Blue Plans Recent government rule changes effective in 2009 enable health plans to enroll and cover some retiree group members in Medicare Advantage (MA) HMO or PPO products, even in areas where a formal provider network is not available. BCBSLA does not maintain a provider network for MA at this time; although, our providers may be asked to service a MA member while they are in our service area. MA members who are enrolled in areas without a provider network (in this case, Louisiana), are non-network members, and may receive care from any Medicare eligible provider, including all Medicare participating providers. BCBSLA network providers are currently encouraged, but not required, to render services to non-network members. Should you decide to provide services to a MA member, you will be reimbursed for covered services at the Medicare Allowed Amount based on where the services were rendered and under the member s out-of-network benefits. Providers should continue to verify eligibility and bill for services for any out-of-state Blue Plan member they agree to treat. Claims are to be submitted directly to BCBSLA. Medicare Advantage Member Servicing Confirmation Form When providing services to a non-network MA member, providers will need to complete a Medicare Advantage Member Servicing Confirmation Form. By completing this form, the provider agrees to provide services to a particular member for the period of time indicated on the form at the Medicare Allowed Amount. Providers may obtain a printable copy of the MA Member Servicing Confirmation Form from the Provider page of our website at under Out-of-State/BlueCard. Submit the form as instructed to network.administrations@bcbsla.com or fax to (225) If you have questions on servicing non-network or out-of-state MA members, contact BCBSLA Provider Services at (800) , option 3 or contact your Provider Relations Representative. To verify benefits, please refer to the number on the member s ID card. Frequently Asked Questions Regarding Treatment of Medicare Advantage Members Q. What steps do I need to take when providing services to a non-network member? A. 1) Verify eligibility by contacting BlueCard Eligibility at (800) 676-BLUE (2583). Be sure to ask if MA benefits apply. 2) Complete a MA Member Servicing Confirmation Form, which indicates that they will provide services to a particular member. The confirmation form also includes the period of time that the services will be provided. Q. Do MA members have a unique identification card? A. MA members will have an identification card that will look the same as other members of the same employer group. All MA cards will have the Medicare Advantage PPO/suitcase-type logo like the one shown here: Q. How do I file a claim for a non-network member? A. Claims are to be submitted directly to BCBSLA. Do not bill Medicare directly for any services rendered to a Medicare Advantage member. Q. How will I be paid for services rendered to a non-network member? A. Non-network members claims will be adjudicated according to the benefits that their health plan provides. The claims will be paid according to CMS guidelines. At a minimum, eligible claims will be reimbursed at the Medicare Allowed Amount based on where the services were rendered and under the member s out-of-network benefits. Q. What is the Medicare Allowed Amount? A. The Medicare Allowed Amount is the fee schedule reimbursement that Medicare would pay to a provider who accepts assignment of benefits for services rendered to a member. Q. Who do I contact if I have additional questions regarding non-network members? A. If you have questions on servicing MA members, contact BCBSLA Provider Services at (800) , option 3 or contact your Provider Relations Representative. 18 Professional Provider Office Manual

20 Medicare Advantage Private Fee for Service Across the country Medicare Advantage plans have introduced Private Fee for Service options. With Private Fee for Service (PFFS), insurers can offer employer groups the same MA plan coverage nationally, without building a provider network. PFFS is a Medicare Advantage plan offered by a health plan that provides coverage for all Medicare Part A and B benefits at a minimum. It may require co-payments from members and pays providers on a fee-for-service basis. PFFS is a non-network plan that does not restrict member choice among providers as long as those providers agree to accept the health plan s terms and conditions of payment and are lawfully authorized to provide services under original Medicare. Who Can Provide Services to MA PFFS Members? MA PFFS Blue Plans use the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Deemed Provider concept, rather than direct contracts, to arrange for services for its MA PFFS members. Most Plans use the following criteria to consider a provider Deemed for rendering services to a MA PFFS member: Provider is aware in advance that the person receiving the services is enrolled in a MA PFFS benefit plan and, Provider has reasonable access to information about the PFFS Plan s terms and conditions of payment and, Provider is lawfully authorized to provide services under original Medicare. General Rule: If a provider is aware that a member is a MA PFFS member, but chooses not to accept the MA PFFS Plan s terms and conditions of payment, they should not provide services to the MA PFFS member, except in urgent or emergency care situations. Recognizing Medicare Advantage PFFS Members Medicare Advantage and PFFS will be indicated on the member s ID card by including the logo shown here. Members will not have a standard Medicare card; instead it will be a Blue Cross and/or Blue Shield ID card. Providers should always ask for the member's ID card. MA PFFS Benefits and Authorizations To verify benefits or obtain authorizations, providers may call the number on the back of the member s ID card, submit an electronic eligibility request through ilinkblue, or call BlueCard Eligibility at (800) 676-BLUE (2583). Be prepared to provide the member s alpha prefix located on the ID card. Submitting MA PFFS Claims When a provider treats a MA PFFS member for covered services, claims are submitted to the local Blue Plan and that Blue Plan then processes the claims through the BlueCard system. For instance, Louisiana providers should submit MA PFFS claims directly to Blue Cross and Blue Shield of Louisiana via their current billing practices. Do not bill Medicare directly for any services rendered to a MA PFFS member. What reimbursement rates apply for MA PFFS patients? Providers will be reimbursed the equivalent of the current Medicare payment amount for all covered services (i.e. the amount you would collect if the member was enrolled in traditional Medicare.) The provider should refer to the member ID card for instructions on how to access terms and conditions. Louisiana providers will receive their reimbursement directly from Blue Cross and Blue Shield of Louisiana the same as other BlueCard members. Collecting member cost sharing amounts at the time of service Providers may collect any applicable cost sharing amount (i.e. copayment, deductible) from MA PFFS members at the time of service. Balance billing may be permitted under some PFFS plans, so refer to the member ID card for instructions on how to access terms and conditions. Disagreements on reimbursement amount received If a provider believes that the payment amount they received for a service (including the member cost sharing collected) is less than they would have received under original Medicare for the service, the provider should contact their local Blue Plan to verify claim payment. Louisiana Providers with questions on serving MA PFFS members may contact BCBSLA Provider Services at (800) , option 3 or contact their Provider Relations Representative Rev 2:1 August 19

21 Section 3: Claims Submission Filing Claims As a participating provider, you agree to submit claims for Blue Cross and Blue Shield subscribers on the CMS-1500 Health Insurance Claim Form. All applicable information should be completed in full, including CPT codes, ICD-9- CM diagnosis codes and applicable medical records to support the use of modifiers or unlisted codes with a charge greater than $300 to ensure payment is made to you accurately and without delay. Claims should include all services rendered during the visit, using a place of service designation 11, office. Our reimbursement allowable for the Evaluation and Management (E&M) service includes the components for physician work, practice expense and malpractice insurance. No additional room usage charge should be billed by any party, since the practice expense component includes overhead expenses, and is an integral part in the E&M or procedure allowable charge. This methodology applies to hospital owned and physician owned practices, and helps ensure that contractual benefits for our members are correctly applied to claims. An example of a claim form and instructions on completing the CMS-1500 claim form are provided in this manual. All completed claim forms should be forwarded to the following addresses for processing: Blue Cross and Blue Shield of Louisiana P. O. Box Baton Rouge, LA FEP claims should be mailed to: Blue Cross and Blue Shield of Louisiana FEP Claims P.O. Box Baton Rouge, LA Timely Filing and Refunds Process All Blue Cross claims must be filed within 15 months of the date of service. Claims received after 15 months will be denied, and the subscriber and Blue Cross should be held harmless for these amounts. Please note: Not all Subscriber Contracts/Certificates follow the 15-month claims filing limit. FEP claims must be filed by December 31 of the year after the year the service was rendered. Medicare claims must be filed within 24 months of the date of service. Self-insured plans and plans from other states may have different timely filing guidelines. Please call Provider Services at (800) to determine what the claims filing limits are for your patients. There may be times when Blue Cross must request refunds of payments previously made to providers. When refunds are necessary, Blue Cross notifies the provider of the claim in question 30 days prior to any adjustment. The notification letter explains that Blue Cross will deduct the amount owed from future payment registers unless the provider contacts us within 30 days. Recoveries and payments for omissions and underpayments shall be initiated within 15 months of the claim s date of payment. Blue Cross and the participating provider agree to hold each other and the subscriber harmless for underpayments or overpayments discovered after 15 months from the date of payment. If Blue Cross has made any omissions or underpayments, the Plan will make payment for such errors as soon as they are discovered or within 30 days of written notice from the participating provider regarding the error. We make every effort to pay claims in a timely manner; however, when a clean claim is not paid on time, we follow the late payment penalty guidelines outlined in House Bill 2052/Regulation 74. Providers automatically receive penalty payment for claims that are not processed in the time frames set forth by House Bill 2052/Regulation 74. The additional payment will almost always appear on the same payment register as the claims payment and can be identified by the status code ST, Statutory Adjustment. Please note: House Bill 2052/Regulation 74 does not apply to FEP, self insured plans, insured ERISA plans, worker s compensation plans or state employee group benefit programs. Also, the late payment penalty does not apply if the claim is delayed through the fault of the claimant. Procedure and Diagnosis Codes and Guidelines Blue Cross uses Physicians Current Procedural Terminology (CPT), ICD-9-CM and HCPCS codes for processing claims. Because medical nomenclature and procedural coding is a rapidly changing field, certain codes may be added, modified or deleted each year. Please ensure that your office is using the current edition of the code book, reflective of the date of service of the claim. The applicable code books include, but are not limited to, ICD-9-CM Volumes 1, 2 and 3; CPT and HCPCS. New CPT codes will be accepted by Blue Cross as they become effective. CPT only copyright 2008 American Medical Association. All rights reserved. 20 Professional Provider Office Manual