2010 BCBSNC Provider Conference Top 20 Questions Answers

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1 Questions Answers There is currently no centralized listing of all out-of-state Blue Plan alpha prefixes. There is a listing available for BCBSNC alpha prefixes only; please contact your Provider Relations representatives to obtain a copy. 1 Do you have a list of states along with their prefixes that you could provide to each practice. The three-character alpha prefix at the beginning of the member s identification number is the key element used to identify and correctly route claims. The alpha prefix identifies the Blue Plan to which the member belongs. It is necessary for confirming a patient s membership and coverage. To ensure accurate claims processing, it is important to capture all ID card data. When a patient has two BCBS policies and the patient is not sure which is primary - we seem to get caught in middle - is there a direct line to call to see which is primary? Usually both BCBS thinks the other is primary. Under BCBSNC policy, when a provider submits a claim for a spouse or a dependent child of a BCBSNC subscriber that reports other coverage but BCBSNC has not received or does not have in its records definitive information to correctly determine liability, BCBSNC will deny the claim and request additional information pertaining to the other coverage. BCBSNC will re-open the claim when the requested information is received within 18 months of the date of service (per the member s benefit booklet) or one year from the date of denial, whichever is later. 2 Provider emanual - section 11.1 Always check the member's ID card and Blue e to determine eligibility and benefit requirements. The Provider emanual is an excellent resource and outlines the mental health authorization process for each line of business: 3 For mental health - how do you know who needs authorization? FEP - section NC Health Choice - section 5.8 Blue Card - section BCBSNC - section 8.11 Page 1

2 For IPP - Why are requested medical records not forwarded to the home plan in a timely manner? This a constant problem that is getting worse. When medical records are requested by BCBSNC, send the records, including the medical request letter received from BCBSNC, to BCBSNC. Upon receipt of the medical records, BCBSNC will forward the records to the member s home plan. Blue Plans are able to send and receive medical records electronically among each other. This electronic method significantly reduces the time it takes to transmit supporting documentation for our out-ofarea claims, reduces the need to request records more than once, and helps to eliminate lost or misrouted records. Occasionally, the medical records you submit might cross in the mail with the remittance advice for the claim requiring medical records. A remittance advice is not a duplicate request for medical records. If you submitted medical records previously, but received a remittance advice indicating records are still needed, please contact BCBSNC to ensure your original submission has been received and processed. This will prevent duplicate records being sent unnecessarily. 4 Provider emanual - section When a claim needs a modifier - 22 and increased reimbursement - do we file the claim electronically and wait for BCBSNC to review /request additional information or do we submit the claim on paper with supporting documentation justifying the use of modifier -22? What do we do if no additional reimbursement is given for the modifier -22? Modifier -22 will not affect claims processing adjudication. In general, BCBSNC does not allow a severity adjustment to fee allowance. Payment for new technologies is based on the outcome of the treatment rather than the "technology" involved in the procedure. For see the BCBSNC corporate medical policy guidlines regarding Modifiers - Page 2

3 What is the preferred method of submitting a corrected claims? Do you accept a corrected professional claim electronically? If so, which re-submission code should be used? A corrected claim is any claim for which you have received a Notification of Payment (NOP)/Explanation of Payment (EOP), and for which you need to make corrections on the original submission. Corrections can be additions (e.g., late charges), a replacement of the original claim, or a cancellation of the previously submitted claim. When submitting a corrected claim, please be sure to include all charges you want to be considered. Providers have the capability to submit corrected claims either electronically through Blue e or on a paper CMS1500 or UB-04 claim form. If filing a corrected claim on paper, write or stamp corrected claim on the top of the claim form. Also, when filing a corrected claim on a UB-04 facility claim form, you must also change the bill type in form locator four (4) to reflect the claim has been corrected. 6 Provider emanual - section How do you avoid duplicate denials for multi-specialty groups (even when they are filed with a modifier)? We are also receiving maternity denials when filing non-global services within the multispecialty group that has both OB & Family practices? The claim for the non-global service should be filed with a non-maternity diagnosis - for example: if the member has diabetes and requires services while pregnant from the OB that are not part of the global reimbursement, the diagnosis should be vs. the maternity diagnosis code. If the patient has diabetes prior to pregnancy and requires treatment for the diabetes outside of the maternity care, the provider should file E&M codes with the diabetes diagnosis code only. Also, if a patient requires treatment from an endocrinologist, the specialty provider should file E&M codes only. If a patient has diabetes as a result of being pregnant (gestational diabetes) and the OB provider requires the patient to be seen more in his office due to this diagnosis, these visits should not be covered as they are a part of the OB global care. BCBSNC does not reimburse providers more for high risk pregnancies i.e. hypertension, obesity. If a patient is being seen in a multispecialty clinic, providers have to be aware that they should not file a maternity diagnosis code on their claim if they are not seeing that patient for the maternity condition i.e. dermatologist, endocrinologist, cardiologist. 8 How do you want us to document a voided claims? Reps keep telling us to do different things. (1) send fax reg void (2) Inquiry notating claim # (3) Voided claim with $0 balance. When filing claims electronically, the 837 (for both Institutional and Professional) uses "8" as indicator for voided claims. For paper UB04 claims, the third position of bill type is "8" for voided claims. For paper CMS1500 claims, the provider should submit a corrected claim with zero charges for each line of service. Page 3

4 When a recoupment is set up, the claim line is shown as a negative. This information includes the member name, member ID#, acct #, DOS, charges, etc. When recoupment's are done on remit there is no identifying information given on who money is taken from - why do you not put ID number, Name or something on recoup to help us identify who to take money from. When we call for information not can help us. If a provider is sent into a negative balance (equivalent of non-sufficient funds), then they will not receive a check. However, they will receive the EOP that shows all of the adjustments without a check. When the next EOP is produced, the negative amount will be deducted from the "to-pay" amount. This can either leave the provider with a reduced negative amount or with a reduced payment. The provider will then be responsible for tracking back through their EOPs. This tracking needs to be done by the provider; however, BCBSNC will be able to assist if necessary. 9 This relates to IPP and Local lines of business only. Q1: Most responses to IPP eligibility requests are returned in less than one minute; a response will indicate as "pending" if no response has yet been received from the member's plan. Q1: When can we expect real time updates on blue e for blue card plans? Q2: When can we expect a VRU that actually works? Two conditions produce a "closed" status. 1) No response was received from the member's plan within 24 hours of the inquiry request (users are advised to call BLUE for eligibility information). 2) A message was received from the member's plan that states "unable to respond at this time." The "closed" status is hyperlinked and can be clicked to retrieve the X12 version of file received from the member's home plan. See Health Eligibility - Blue e online Help System. Q2: BCBSNC has introduced a number of enhancements in our voice recognition (VRU) program and in our call routing that was designed to improve the provider's experience. We have edited the voice prompts within the VRU to remind providers that they can "press or say" their NPI or Tax ID#. 10 BCBSNC is aware of and are working on enhancements to the VRU system; we know it is a difficult point in our voice recognition for both members and providers. We are working with our IS team to make enhancements to allow for a more positive experience when calling into Customer Service. Page 4

5 The Blue Medicare HMO and Blue Medicare PPO resources and information page for providers can be found on the bcbsnc.com web site located at: Help with the Partners website. Error with set-up for HealthTrio - the sites I need access to check status/eligibility on are not available. I have been unable to get assistance with this. HealthTrio Connect remains the secure Internet site for conducting electronic transactions for Blue Medicare HMO and Blue Medicare PPO member services. If your health care organization currently use Blue e, it s important to note that Blue e cannot be used to conduct transactions for the Blue Medicare HMO and Blue Medicare PPO products. For assistance with the HealthTrio Connect system, please call If you re in need of assistance and want to speak with Customer Service about a Blue Medicare HMO or Blue Medicare PPO related issue, call us on the Provider Line using the same phone number or if calling locally (336) The office visit copay is listed on many ID cards, but why is the Preventive Office visit copay not listed when it usually is different? Blue E only says "covered service". Why do ID cards have an "issue date" instead of the "effective date"? BCBSNC redesigned our member ID card in mid-october 2008, as part of an overall Blue Cross and Blue Shield Association effort to standardize ID cards for all Blue members nationwide. The Association wants to ensure that the benefit information on the cards is consistent, easy to find and understand. Additionally, a North Carolina Senate bill, effective January 1, 2009, requires that all insurers list certain copayments on ID cards, as well as either the effective date of coverage or the issue date of the card. Benefits displayed on the ID card will reflect the NCDOI-required copayment information and benefit information most commonly used at the time of service by providers and members. 12 ID cards will reflect the "Date Issued," which will be either 1) the effective date, if the card is printed before the effective date; or 2) the current or print date, if the card is printed on or after the effective date. 13 NC Health Choice - Vision Benefits 9 claims 30% of our children at our practice have this coverage. We continue to get denials on optical (eyeglasses) when we bill for lens, standard, bifocal, progressive, etc. Define the standard under Medicaid guidelines with NC Health Choice plans. Benefits for NC Health Choice members are administered by the North Carolina Division of Medical Assistance (DMA) and the medical policy is available at Page 5

6 The look back period for BCBSNC requesting a refund from providers varies based on the line of business: FEP - No limitation on the look back period for refunds. You want a refund of payment - How long can you legally request a refund? NC Health Choice - Refund requests are typically limited to overpayments that exceed two (2) years, unless a refund is deemed appropriate by the claims processing contractor or the executive administrator. The two year time frame is calculated by date of identification to the date of payment, and applies to standard refund request only. Blue Card - IPP Blue Card will limit initiation and pursuance of Overpayment recoveries to an eighteen (18) month timeframe from the date of the original claim payment with the following exceptions: fraud; contractual requirements of self-funded groups; contractual requirements of certain Provider contracts; statutory or regulatory compliance; unsolicited or self-reported refunds. BCBSNC - BCBSNC will limit initiation of overpayment recoveries to an eighteen (18) month timeframe from the date of the original claim payment with the following exceptions: fraud; contractual requirements of self-funded groups; contractual requirements of certain Provider contracts; statutory or regulatory compliance; unsolicited or self-reported refunds. 14 The Provider Blue Line can also assist with information pertaining to refund requests. Please describe the levels of BQPP and what is required to reach each level. Also, give an idea of how the incentives to reach each level are set up. The Blue Quality Physician Program (BQPP) has been designed to recognize and reward eligible physicians who demonstrate a strong commitment to patient-centered care, quality of care, and administrative efficiency. The Blue Quality Physician Program is based upon objective, agreed-upon data as determined by the National Committee for Quality Assurance and other organizations. The national quality movement in health care has focused on several key measures, including clinical quality outcomes, administrative efficiency and patient experience with care. Physicians participating in the program earn higher reimbursement for meeting criteria based on these measures. 15 For questions about participating in the Blue Quality Physician Program, contact your Network Management Provider Relations Representative. Page 6

7 Unsolicited Medical Records? Is it okay to call BCBS to find out what records are needed & then to send or do you have to have the BCBS request for medical records? Can the Medical records request be faxed to us? When medical records are needed to complete the processing of a claim we will notify the provider whom records are needed from in writing using a BCBSNC medical records request form. If your practice would like to be set-up to receive medical records requests via fax, please contact the Customer Service Provider Line for assistance The medical records request form contains a routing code that allows the records to be scanned and sent directly to the individual in claims review, who is waiting to complete the processing of the pending claim(s). When sending medical records, always include the medical record request form, as the top sheet, on top of the medical records. For FEP members, the EOP is the official request for medical records and you must include the EOP when send the medical records to FEP. 16 Do not send medical records unless requested by BCBSNC. 17 Q1: On the rejected claims report can we see why it's rejected? If not, can that be upgraded? Q2: How long does it take to update Blue e? Q3: Can you update Blue E to show auth#'s for each patient? Q1: The Claims Audit Report displays a detailed explanation of HIPAA Implementation Guide (IG) and BCBSNC business error claim rejections. Q2: Claim status is updated real-time in Blue e. Member eligibility/benefits are updated in Blue e nightly. Q3: The Case Status Inquiry transaction displays the status (example-approved, denied, modified, etc. )of authorization requests. But, at this time, this transaction is only available for hospitals. BCBSNC recognizes all nationally accepted and recognized modifiers per CPT guidelines - not all modifiers will affect payment. 18 Why does BCBCNC only recognize the first modifier? Please see the BCBSNC corporate medical policy guidlines regarding Modifiers Are EFT's available for FEP? Unfortunately, at this time the Federal Employee Program (FEP) does not have the capability to send provider payments via EFT. Page 7

8 A duplicate claim is any claim submitted by a provider for the same service and same charge amount provided to a particular individual on a specified date of service that was included in a previously submitted claim. Providers should carefully review Blue e and their electronic claim response reports to ensure that all of their electronic claims were accepted into the claims system. Rejected claims should be corrected and resubmitted electronically. Resubmission of claims accepted into the claims system will cause the new claim to be rejected as a duplicate and delay the entire adjudication process. 20 Duplicate claim If you do not receive a response from your original claim submission, please verify claim receipt via Blue e or call BCBSNC Customer Service for additional assistance. Page 8