1 1 Blue Medicare PPO Physician & Other Professional Provider Orientation as of May 2009 A product of HCSC Insurance Services Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2 2 Purpose of Presentation To provide an overview of the policies & procedures for the Blue Medicare PPO plan for the Blue Medicare PPO Participating Physicians/Professional Providers
3 3 Blue Medicare PPO Overview A Medicare Advantage product for people with Medicare An additional health benefit solution for people with Medicare Offers more comprehensive benefits at a lower cost to people with Medicare whenever people with Medicare access Blue Medicare PPO Participating Physicians/Professional Providers
4 4 What is Blue Medicare PPO? Blue Medicare PPO is a Medicare Advantage product offered by HCSC Insurance Services Company (HISC). It is a preferred provider organization (PPO) plan offered to Medicare Part A and B Members in the 5 approved Texas counties: El Paso Galveston (TE: Limited to the Mainland portion of Galveston county*) Harris Jefferson Montgomery *The only zip codes included for Galveston county: 77510, 77517, 77518, 77539, 77546, 77549, 77552, 77553, 77555, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592, 77617, and 77650
5 5 To Participate in the Blue Medicare PPO, Physicians/Professional Providers: Must be a Participating BlueChoice Physician/Professional Provider Must have privileges at one of the Blue Medicare PPO participating hospitals (unless inpatient admissions are uncommon or not required for the Physician s/professional Provider s specialty) must have a valid National Provider Identifier (NPI) Number Must sign a Blue Medicare PPO amendment to his/her BlueChoice agreement, and Cannot have opted-out of Medicare or have any sanctions or reprimands by any licensing authority or review organizations. Blue Medicare PPO Participating Physicians/Professional Providers cannot be named on the Office of the Inspector General (OIG) or Government Services Administration (GSA) lists which identify physicians/professional providers found guilty of fraudulent billing, misrepresentation of credentials, etc. Blue Medicare PPO Participating Physicians/Professional Providers cannot be sanctioned by the Office of Personnel Management or be prohibited from participation in the Federal Employees Health Benefit Program (FEHBP).
6 6 Blue Medicare PPO Participating Hospitals Facility Name County Facility Name County Del Sol Medical Medical Center El Paso Memorial Hermann Hospital Harris El Paso Psychiatric Hospital El Paso Memorial Hermann Memorial City Hospital Harris Highlands Regional Rehabilitation Hospital El Paso Memorial Hermann Northeast Hospital Harris Las Palmas Medical Center El Paso Memorial Hermann Northwest Hospital Harris R E Thomason Medical Center El Paso Memorial Hermann Prevention and Recovery Center Harris Memorial Hermann Katy Hospital Fort Bend Memorial Hermann Prevention and Recovery Center Northwest IOP Harris Memorial Hermann Sugar Land Hospital Fort Bend Memorial Hermann Southeast Hospital Harris Devereaux Texas Treatment Center Galveston Memorial Hermann Southwest Hospital Harris Mainland Medical Center Galveston Park Plaza Hospital Harris Bayshore Medical Center Harris Spring Branch Medical Center Harris Children s Memorial Hermann Hospital Harris St. Joseph Medical Center, Harris County Harris CHRISTUS St. John Hospital Harris St. Luke s Episcopal Hospital Harris Clear Lake Regional Medical Center Harris Texas Orthopedic Hospital Harris Clear Lake Rehabilitation Hospital Harris The Woman s Hospital of Texas Harris Cypress Fairbanks Medical Center Harris TIRR (The Institute for Rehabilitation and Research) Harris East Houston Regional Medical Center Harris West Houston Medical Center Harris Harris County Psychiatric Center Harris CHRISTUS Hospital (Beaumont) Jefferson Houston Northwest Medical Center Harris CHRISTUS Hospital (Port Arthur) Jefferson IntraCare Downtown (Medical Center) Hospital Harris Conroe Regional Medical Center Montgomery Intracare North Hospital Harris Memorial Hermann Prevention and Recovery Center The Woodlands IOP Montgomery Kingwood Medical Plaza Harris Memorial Hermann The Woodlands Hospital Montgomery Memorial Hermann Heart & Vascular Institute Southwest Harris
7 7 Blue Medicare PPO Major Characteristics Blue Medicare PPO Participating Physicians/Professional Providers may only collect for copayments, cost share (coinsurance) and deductibles, if applicable. To receive in-network benefits, Blue Medicare PPO Members must receive medical care from Blue Medicare PPO Participating Physicians/Professional Providers. Referrals are not required if Blue Medicare PPO Members receive medical care from Blue Medicare PPO Participating Physicians/Professional Providers. TE: Blue Medicare PPO Members may self-refer to Blue Medicare PPO Participating Specialty Care Physicians/Professional Providers. For Blue Medicare PPO Members to receive in-network benefits, referrals to out-of-network physicians/professional providers which are necessary due to network inadequacy or continuity of care must be authorized by the Utilization Management (UM) Department prior to the services being rendered.
8 8 How Will BlueCard Work With Blue Medicare PPO? BlueCard does not apply to Blue Medicare PPO. However, if a New Mexico Blue Medicare PPO Member sees a Texas Blue Medicare PPO physician/professional provider, the claim will process at the in-network benefit level. Similarly, if a Texas Blue Medicare PPO Member sees a New Mexico Blue Medicare PPO physician/ professional provider, the claim will process at the in-network benefit level.
9 9 Benefits, Eligibility or Claims Status To check benefits, eligibility or claims status, call Blue Medicare PPO Provider Customer
10 10 Blue Medicare PPO Member ID Card Sample Card Note: Office visit copayments: $10 = Primary Care Physician; $40 = Specialty Care Physician/Professional Provider Office visit copayment is determined by how a physician/professional provider is contracted for BlueChoice. If the physician is contracted for BlueChoice as a Primary Care Physician, the physician should collect the $10 copayment. If the physician/professional provider is contracted for BlueChoice as a Specialty Care Physician/Professional Provider, the physician/professional provider should collect the $40 copayment. If the physician is contracted as a Primary Care Physician and a Specialty Care Physician, then the physician should collect the $10 copayment.
11 11 Blue Medicare PPO Member ID Card, cont d Blue Medicare PPO Participating Physicians/Professional Providers are encouraged to do the following: Ask for the Member s ID card at the time of each office visit; Copy both sides of the Member s ID card and place the copy in the Member s office file; Call the toll-free Blue Medicare PPO Provider Customer Service number indicated on the back of the Member s ID card to: check benefits and eligibility inquire about claim status or a claim problem Utilize the iexchange Web Application at or the iexchange Interactive Voice Response (IVR) phone system or call the UM Department at the toll free numbers indicated on the Key Contacts page for the following: to obtain precertifications to contact Case Management/Disease Management Programs, or to notify Blue Medicare PPO within one (1) business day of an emergency hospital admission. In-Network benefits for an out-of-network provider due to extenuating circumstances such as network inadequacy or continuity of care must be preauthorized by UM. Please call the UM Department directly at the number indicated on the Key Contacts Page. For detailed information, Access the BlueChoice Physician & other Professional Provider - Provider Manual (under Provider Library area, select Provider Manuals, password manual ), and, Access the Blue Medicare PPO Supplement (under Provider Library, select Blue Medicare PPO)
12 12 Claims Submission Information Blue Medicare PPO claims should be submitted electronically through the Availity Health Information Network for processing. Blue Medicare PPO Electronic Payor ID # TXPPO For information on electronic filing of Blue Medicare PPO claims, contact the Availity Health Information Blue Medicare PPO claims must be submitted within 180 days of the date of service. Claims that are not submitted within 180 days from the date of service are not eligible for reimbursement. Blue Medicare PPO Physicians/Professional Providers may not seek payment from the Member for claims submitted after the 180 day claims filing deadline. Blue Medicare PPO may be submitted Electronically in the CMS National Standard Format (NSF) or the current version of the ANSI83 format or on a completed version of the applicable CMS claim form and mailed to: Blue Medicare PPO P.O. Box 3567 Scranton, PA Blue Medicare PPO claims (electronic & paper) must be filed with the Member s complete ID number - exactly as shown on the Member s ID card including the 3-digit alpha prefix ZGD. Duplicate Blue Medicare PPO claims may not be submitted prior to the applicable 30-day (electronic) or 45-day (paper) claims payment period
13 13 Claim Disputes Blue Medicare PPO Participating Physicians/ Professional Providers may dispute a claims payment decision by requesting a claim review. If you have questions regarding a claims dispute, please contact the Blue Medicare PPO Provider Customer Service
14 14 Precertifications, Utilization Management, Case Management & Disease Management Programs Precertification: Utilize the iexchange Web application at or the iexchange Interactive Voice Response (IVR) phone system at Current listings of Blue Medicare PPO Participating Physicians/Professional Providers are available For more information on the precertification process, refer to the enclosed copy of the BlueChoice Physician & other Professional Provider - Provider Manual or access the BlueChoice Physician & other Professional Provider - Provider Manual (under Provider Library area, select Provider Manuals, password manual ), and, refer to the Blue Medicare PPO Supplement (under Provider Library area, select Blue Medicare PPO) Case Management, Disease Management Programs or Utilization Management: For Case Management or Disease Management Programs call , or For the Utilization Management (UM) Department call
15 15 If iexchange is unavailable, call or fax information to the following numbers: Precertification Phone Precertification Fax
16 16 Blue Medicare PPO Precertification Requirements List Service Precertification Requirements Inpatient Hospital Admissions Ambulance Services Bone Mass Measurement Chiropractic Services Colorectal Screening Exams Diabetes Self Monitoring Training and Supplies Doctor Office Visits (PCP or Specialist) YES YES Air Ambulance only Durable Medical Equipment YES > $2500 Emergency Care Home Health Care / Home Infusion Therapy (HIT) Hospice Care Immunizations (Flu, Hepatitis B for At Risk and Pneumonia) Laboratory Services (Outpatient) Mammograms (Annual Screening 40+) Out-of-Network Services Outpatient Services (Outpatient Facility Based Services not included on this list) Pap Smears and Pelvic Exams Podiatry Services Prostate Cancer Screening Exams YES YES YES If In-Network Benefit Level is Requested Prosthetic Devices YES > $2500 Radiology Services (Outpatient) Rehabilitation (Outpatient) Skilled Nursing (In a Medicare Certified Nursing Facility) Substance Abuse Care (Inpatient & Outpatient) YES High Tech Imaging Services only YES Home Setting only YES YES All levels of care TE: Whether the services are Medically Necessary must be determined before a precertification number will be issued. Claims received that do not have a precertification number will be denied. Blue Medicare PPO Physicians/Professional Providers may not seek payment from the Member when a claim is denied for lack of a precertification number.
17 17 Laboratory Services Laboratory Corporation of America (LabCorp) is the participating lab for outpatient clinical reference laboratory services For LabCorp locations or questions, contact LABCORP or visit LabCorp s Web TE: If lab services are performed at the participating Physician s/professional Provider s office, the Physician/Professional Provider may bill for the lab services. However, if the Physician s/professional Provider s office sends the lab specimens to a contracted lab for completion, only the contracted lab can bill Blue Medicare PPO for the lab services.
18 18 Radiology Services Outpatient, Non-Emergency Diagnostic High Tech Imaging Services American Imaging Management, Inc. (AIM) will be responsible for managing outpatient, non-emergency diagnostic high tech imaging services for Blue Medicare PPO Members. The ordering Physician/Professional Provider must contact American Imaging Management (AIM) to obtain a precertification number for the following outpatient, non-emergency diagnostic high tech imaging services when performed in a Physician s/professional Provider s office, outpatient department of a hospital or a freestanding imaging center: - CT / CTA Scans - MRI / MRA Scans - SPEC / Nuclear Cardiology Studies - PET Scans (TE: Whether the services are Medically Necessary must be determined before a precertification number will be issued. Claims received that do not have a precertification number will be denied. Blue Medicare PPO Physicians/Professional Providers may not seek payment from the Member when a claim is denied for lack of a precertification number.) To obtain a precertification number, contact AIM as follows: Call Center: Internet: FAX: For a listing of imaging provider locations, contact or For routine radiology services that are not part of the precertification process above, refer to the enclosed BlueChoice Physicians and other Professional Provider Provider Manual or access (under Provider Library area, select Provider Manuals, password manual ). For more detailed information, refer to the enclosed Blue Medicare PPO Supplement or access (under Provider Library area, select Blue Medicare PPO).
19 19 Behavioral Health (Mental Health & Chemical Dependency) Magellan Behavioral Health, Inc. coordinates the behavioral health (mental health & chemical dependency) services for Blue Medicare PPO Members The Member s Participating Physician/Professional Provider must contact Magellan Behavioral Health, Inc. to obtain a precertification for inpatient and outpatient behavioral health services Precertification must be obtained prior to the delivery of inpatient & outpatient behavioral health services. To obtain precertification, call Magellan Behavioral Health, (TE: Whether the services are Medically Necessary must be determined before a precertification number will be issued. Claims received that do not have a precertification number will be denied. Blue Medicare PPO Physicians/Professional Providers may not seek payment from the Member when a claim is denied for lack of a precertification.) To obtain benefits and eligibility call Blue Medicare PPO Provider Customer Blue Medicare PPO claims should be submitted electronically to Blue Medicare PPO Blue Medicare PPO Electronic Payor ID # - TXPPO If the behavioral health professional must file a paper claim, mail claim to: Blue Medicare PPO, P.O. Box 3567, Scranton, PA For claims processing questions or status, call Blue Medicare PPO Provider Customer
20 20 Provider Identifier & Network Effective Date A minimum of 30 days advance notice is required when making changes affecting the Physician s/professional Provider s BCBSTX status, especially in the following areas: 1. Physical address (primary, secondary, tertiary); 2. Billing address; 3. National Provider Identification (NPI) number, Tax Identification Number or Social Security Number changes; 4. Moving from Group to Solo practice; 5. Moving from Solo to Group practice; 6. Moving from Group to Group practice; and, 7. Backup/covering Physicians/Professional Providers. Provider identifier effective date will be established as of the date the completed provider identifier application is received in the BCBSTX corporate office. This applies to additions, changes and cancellations. BCBSTX will not add, change or cancel information related to the provider identifier on a retroactive basis. Retroactive provider identifer effective dates will not be issued. Retroactive network participation will not be issued. Delays in status change notifications will result in reduced benefits or non-payment of claims filed under the new provider identifier. If the Physician/Professional Provider files claims electronically and their provider identifier has changed, the Physician/Professional Provider must contact to obtain a new EDI Agreement. For provider identifier questions or to obtain a provider identifier application, please contact the BCBSTX Provider Services department at , press 3.
21 Blue Medicare PPO Key Contacts Blue Medicare PPO Provider Customer Service (To obtain Benefits, Eligibility or Claims Status) Utilization Management (UM): (Precertification) Percertification - iexchange Web Application - iexchange Interactive Voice Response System - Precertification (If iexchange system is unavailable) M-F 8am 5pm CST & MST Precertification Fax Case Management/Disease Management Programs Case Management/Disease Management Programs Fax American Imaging Management (AIM): - Call Center Internet -Fax Laboratory Corporation of America (LabCorp) LABCORP - LabCorp s Web site Address Electronic Claim Questions or Problems - Availity Health Information Network - Availity Web site Address Blue Medicare PPO Claim Address (For submission of paper claims) Behavioral Medicine (BH): - Magellan Behavioral Health, Inc. (For Precertification of Inpatient & Outpatient Care) - Blue Medicare PPO Provider Customer Service (To Obtain Benefits, Eligibility or Claims Status) Provider Status (To verify, access the On-line Provider Directory) CMS Web site Blue Medicare PPO P.O. Box 3567 Scranton, PA www,bcbstx.com/provider 21
22 Thank you for reviewing the orientation presentation. Should you have any questions or need additional information, please contact your local Professional Provider Network office.
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