Mental Health/Substance Abuse Provider Orientation

Transcription

1 Mental Health/Substance Abuse Provider Orientation Blue Cross Blue Shield of Vermont (BCBSVT)

2 Welcome to Blue Cross Blue Shield of Vermont Our Vision A transformed health system in which every Vermonter has health care coverage, and receives timely, effective, affordable care Our Mission We are committed to the health of Vermonters, outstanding member experiences, and responsible cost management for all of the people whose lives we touch. 2

3 Commitment to providing quality care Blue Cross Blue Shield of Vermont network providers share a commitment to improve the quality of our members lives by rendering quality care. Our network providers demonstrate this commitment by assuring the following: o Complying with credentialing requirements in a timely manner o Obtaining authorization for care as required by the member s benefit plan o Rendering care in accordance with BCBSVT s clinical practice guidelines when appropriate o Participating in treatment record reviews when requested 3

4 Commitment to providing quality care o Informing members of their rights and responsibilities and the importance of collaborating with their primary care provider and others involved in their healthcare. o Initiating and maintaining ongoing communication with the primary care provider when authorized by the member. if a member declines to give authorization to communicate with the PCP, please document the refusal in the member s record o Help to recognize, fraud, waste and abuse o Complying with all policies and procedures contained in the Blue Cross Blue Shield of Vermont Provider Manual (located at ) 4

5 Accessing the BCBSVT website Our website contains two options to obtain valuable information: Non-secure Home Page o General information available to the public Secure Resource Center o Practice and Member specific information Registration is key to successful business efficiencies. To register go to: 5

6 Accessing the BCBSVT Non-Secure website Home Page Communications Medical Policies Provider Manual & Reference Guides Forms EFT Electronic Funds Transfer Electronic Business (Electronic claims and electronic remittance advice transaction information) Contracting, Enrollment, Credentialing & Demographics Changes Contact us (listing of telephone numbers for interacting with our Plan) 6

7 Accessing the BCBSVT Secure website Resource Center (Secure: must register for user name and password at PracticeTax ID level) Eligibility and Benefit Search Claim Status Inquiry Prior Approvals/Pre-Notification/AcuExchange Clinical Manuals Tools and Resources Committee & Meeting Minutes Motivational Posters Tools Available o Clear Claims Connection (C3) to view claims editing rules. o National Drug Code (NDC) Tool BCBSVT Policies 7

8 Provider Communication Channels Pre-Notification/Authorization Requests AcuExchange Online Prior Approval o Immediate approval for certain requests o (log onto our secure Provider Resource Center) Call: (800) Fax: (802) , or Mail to: Blue Cross Blue Shield of Vermont Attn: Integrated Health Management PO Box 186 Montpelier, VT For complete overview and training of the online prior approval process contact your provider relations consultant. (Contact list available at 8

9 Electronic Funds Transfer (EFT) Replace paper-based claims payments Direct deposits into your bank account Funds are available to you sooner No cost - enrollment is easy and timely Remittance Advices available to download or print Complete online form at Emdeon.com/eft Call Download form at emdeon.com/epayment Fax Mail to: Emdeon Electronic Payment Service Enrollment Request PO Box Nashville, TN

10 Provider Communication Channels Local Member Eligibility o (log onto our secure Provider Resource Center) o Customer Service (888) Local Claims Status o (log onto our secure Provider Resource Center) o Customer Service (888) BlueCard (out of area members) Eligibility/Benefits o (log onto our secure Provider Resource Center) o Phone: (800) o Be sure to use the member s three-digit alpha prefix that is located on their ID card. BlueCard (out of area members) Claim Inquiries o (log onto our secure Provider Resource Center) o Phone: (800) o Be sure to use the member s three-digit alpha prefix that is located on their ID card. 10

11 Provider Communication Channels Federal Employee Program(FEP) Eligibility/Benefits and Claim Status o (log onto our secure Provider Resource Center) o Phone: (800) A full list of contacts is available on our website under 11

12 Provider Communication Channels To assist with contractual or educational issues or to schedule an educational conference call or in-person site visit, contact: Provider Relations Consultant Susan Eastman o Mail: Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT o eastmans@bcbsvt.com o Phone:Toll Free (888) option #1 then option #3; or Direct (802) o Efax: (866)

13 Claims Submission Claims submission instructions can be found on our website at Professional Billing - see CMS 1500 Paper Claim Billing Instructions Facility billing see UB-04 Billing Instructions Options to submit claims: For electronic submission o For an approved list of Clearinghouses and Vendors, please refer to our website at For paper claims submission, please mail to (faxes are not accepted): Blue Cross Blue Shield of Vermont PO Box 186 Montpelier, VT

14 Claims Submission How to correct a previously submitted claim Instructions are provided on our website at under: o Corrected Claim Submission Guidelines Claims Submission Guidelines for Providers With More than One Blue Plan Contract Instructions are provided on our website at 14

15 CPT Coding Clarification Time Rule AMA determination: A unit of time is attained when the mid-point is passed When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used. With Psychotherapy Codes: o 30 minutes (16 37 minutes) i.e.: 90832, o 45 minutes (38 52 minutes) i.e.: 90834, o 60 minutes (53+ minutes) i.e.: 90837, o Psychotherapy never less than 16 minutes o Psychotherapy for Crisis first 60 minutes ( minutes) additional 30 minutes (16 37 minutes) 15

16 CPT Coding Clarification Add-on Codes Add-on codes are used by a medical provider when psychotherapy is performed in addition to an Evaluation & Management (E&M) service, they are: Psychotherapy 30 minute add-on Psychotherapy 45 minute add-on Psychotherapy 60 minute add-on 16

17 CPT Coding Clarification Below are links that will assist you with any questions or details around coding requirements: American Psychological Association (APA) coding and billing instructions Website: Search for: coding and billing National Association of Social Workers (NASW) Billing Codes Website: In the Trending Topics in Practice section select Clinical Social Work 17

18 CPT Coding Clarification Below are links that will assist you with any questions or details around coding requirements (continued): APA Practice Central Psychotherapy Codes for Psychologists Website: Search for: billing and coding American Psychiatric Association (APA) coding and reimbursement Website: Search for: coding and reimbursement 18

19 Authorization Requirements For Non-FEP (Federal Employee Program) & Non-BlueCard Prior Approval is required for all psychological testing, electroconvulsive therapy (ECT) and all higher levels of care such as intensive outpatient, partial hospitalization services, residential and inpatient admissions. o The prior approval forms and the complete list of Services and Diagnosis Requiring Prior Approval document is available on our website at o Non-contracted (out-of-network) providers require prior authorization for all services. To discuss care management options for a member, contact our Integrated Health Management Department at (800)

20 Authorization Requirements FEP (Federal Employee Program) Prior approval is required for inpatient admissions. Non-contracted (out-of-network) providers require prior authorization for all services. 20

21 Authorization Requirements Blue Card (Out-of-Area members) To determine authorization requirements for an out-of-area member, contact the BlueCard Eligibility line below: o BlueCard Eligibility/Benefits o Phone: (800) o Note: Be sure to have the member s three-digit alpha prefix available. You can locate the prefix on the member s ID card. 21

22 Authorization Requirements For Local Business You can find a complete list of services requiring prior approval/authorization at: in the Prior Approval/Authorization section under Requirements and Forms. Important: Please note, these documents are updated frequently. It is important to confirm requirements on a regular basis to avoid potential claim denials resulting in provider liability. Note: There are different prior approval lists based on the members benefit. 22

23 CAQH Application (Council for Affordable Quality Healthcare) You must complete/maintain an updated online CAQH credentialing application. Below are some important tips: To register: o If you are a provider go to: o If you are a practice manager go to: Be sure to update expired elements on the application. Signed attestations are required on routine intervals (approx. every 3 months). All required documents and current information is needed before an application can be processed. (i.e. License, DEA (if applicable) and Malpractice insurance) CAQH does not do the primary source verification. Primary source verification is completed by MedAdvantage. Include all the practitioner s service sites including any private practice sites and/or all group practice sites. Correctly save updates made to data on practitioner s application. Update all information pertaining to admitting privileges (if applicable) Keep contacts current to assure receipt of critical reminders from CAQH. For full credentialing and re-credentialing details, refer to Section 1 of our Provider Manual on our website at 23

24 Re-Credentialing Providers are re-credentialed every three years subject to accrediting bodies, the provider contract and applicable state law to monitor provider network quality. Re-credentialing is the process of re-reviewing and re-verifying a provider s professional credentials in conjunction with BCBSVT s credentialing criteria. Be sure that your most recent License, DEA and Malpractice Insurance documentation are on file. Be sure you re-attest after each CAQH reminder notification. Notification letters are sent prior the provider s anniversary date if CAQH is not in an acceptable status. Termination notices will be sent if a response is not received. 24

25 Updating your practice information Forms are located on our website at: in the Contracting, Enrollment, Credentialing & Demographics Changes section. Each form provides instructions on how to complete. Provider Enrollment/Change Form (PECF) To add a new provider to a practice To add/delete a location To make a change to an individual provider name To terminate an individual provider To update demographic locations To update provider credentials 25

26 Updating your practice information Group Practice Enrollment/Change Form (GPECF) For changes at the Billing (TAX ID/Vendor NPI) level for your Group or Individual Practice o Change in Group or Practice physical address and/or phone number o Change in Group or Practice payment address and/or phone number o Change in Group or Practice Correspondence address o Change in Group or Practice Tax ID o Change in Group or Practice Name o Change in Group or Practice National Provider Identifier (NPI) Area of Expertise To notify us of areas you specialize Trainee Declaration To enroll clinicians, who are working toward licensure, who provide services to our members. Services provided by clinicians that meet the requirements can bill services by the supervising clinician. The policy and form are available on our website at Each form provides instructions on how to complete. 26

27 Quality Review (QI) Program Blue Cross and Blue Shield of Vermont and The Vermont Health Plan s Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members. Through collaboration with community providers we offer Relevant clinical guidelines Member and Provider Satisfaction Survey Open communication to member complaints HEDIS and Quality data gathering Measurable projects around specific clinical issues Clinical Advisory Committee Please contact your Provider Relations Consultant for more information or collaboration opportunities. 27

28 Integrated Health Management Integrated Case Management/Care Coordination For any members who need extra care or assistance Our professional staff of in-house registered nurses and social worker case managers provide individual attention to members experiencing health complexity with a whole person approach to care and services. Physical Health, Mental Health, Substance Use Comorbidities, High risk Pregnancy Multiple diagnosis Serious and chronic illnesses Impairment and disability Personal, social and financial upheaval Health system issues Participation is voluntary and available at no cost and offers caring, individualized support through: Coordination of services Communication between multiple providers Health benefit navigation Education Problem solving Community resources For more Information contact the Integrated Health Management team at (800) Option 1 28

29 Fraud, Waste and Abuse (FWA) What you need to know about it and what we can all do to stop it Definitions: Fraud o Fraud is intentional misrepresentation; deception; intentional act of deceit for the purpose of receiving payments that an individual or entity is not eligible to receive. Waste o Waste generally refers to over utilization of medical services, behaviors or practices that result in unnecessary costs, misuse of resources, and that may also be inconsistent with acceptable medical guidelines. They may often be of no medical or clinical value, and may be more directly related to health management. Abuse o Abuse is deliberate ignorance or reckless disregard of the truth; conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in payments that an individual or entity is not eligible to receive. 29

30 Fraud, Waste and Abuse (FWA) What is the difference between Fraud and Abuse The major difference between fraud and abuse is in the area of intent. In fraud the intent is to deceive or misrepresent. With abuse the intent is not criminal, but the acts are inconsistent with accepted sound medical, business, or fiscal practices which directly, or indirectly, create unnecessary costs. Types of Fraud, Waste and Abuse Fraud and Abuse Billing for services not rendered Billing for medically unnecessary services Misrepresentation of services or dates of service Misrepresentation of identity (identity theft) Up-coding Unbundling Purposely misrepresenting a condition or the types of services provided Altered claims or prescriptions Waiver of deductible, co-insurance and/or co-payment Doctor Shopping Waste Unnecessary services Services where costs were inflated Excessive administrative costs Services delivered inefficiently Services where prevention opportunities were missed 30

31 Fraud, Waste and Abuse (FWA) Several Simple Ways Providers can help prevent Fraud, Waste and Abuse Causes: Inevitable gaps in the complex healthcare system Opportunities to violate trust Dishonesty Ways to prevent fraud Confirm patient identification. o Ask for a picture ID (and keep a copy) to ensure that the person presenting the insurance card is the actual owner of that card. Protect your prescription forms to avoid theft of private information Check patient histories to help prevent prescription drug fraud. Ask patients if they are seeing or have obtained prescriptions from other doctors. Verify that billing codes are accurate and that documentation in the clinical record is complete Implement procedures to ensure that information, such as the nature of services provided, is accurately communicated to your billing staff and to any third-party firms and services. 31

32 Fraud, Waste and Abuse (FWA) Be part of the solution Healthcare FWA affects every patient, provider and hospital in the country wasting billions of dollars every year BCBSVT is committed to stopping healthcare fraud, waste and abuse. Help us eliminate this costly problem If you suspect FWA call the BCBSVT Fraud Hotline or us at 32

33 Thank you for the service you provide our members and for choosing Blue Cross Blue Shield of Vermont 33