Highmark Blue Shield Provider Information Management P.O. Box Camp Hill, PA

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1 Dear Health Care Professional: The enclosed forms are provided to process your request for an Assignment Account number with Highmark Blue Shield. An Assignment Account is Highmark Blue Shield s term for a single provider or group of providers who wish to assign their right of payment to a single entity under a tax identification number. All providers who wish to be enrolled in the Assignment Account must have a Highmark Blue Shield provider number. If any provider does not have a number, they must complete the Provider Application to be enumerated on our file and cross-referenced to the group. Participating Status of Assignment Account The participating status of the Assignment Account is based on the individual provider s participating/ non-participating status with Highmark Blue Shield. Mixed Assignment Accounts of participating and non-participating providers will not be approved. Providers who are not already participating with Highmark Blue Shield must complete a Participating Provider s Agreement. The provider must be licensed in Pennsylvania in order to qualify for participation. If the Assignment Account is to be used for the Keystone Health Plan West (KHPW) Programs, the account will not be effective until the appropriate KHPW Professional Provider Agreement(s) have been executed. After you have signed and returned the Agreement(s), you will receive a welcome letter from KHPW that will advise you of the effective date of such agreement(s). For questions specific to your practice and on establishing your assignment account, please contact your Provider Relations Representative. For questions on your assignment account after you have submitted your Request for an Assignment Account, please contact Provider Information Management, toll-free at Please return the completed application to: Highmark Blue Shield Provider Information Management P.O. Box Camp Hill, PA You may not bill under the assignment account name until you receive an approval letter specifying your Assignment Account number and its effective date. Camp Hill PA Highmark Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association 3975 S 07/08

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3 Assignment Account Guidelines I. Introduction An assignment account is an account established by Highmark Blue Shield to permit one or more individual providers, practicing together, to direct Highmark Blue Shield payments to an entity other than the individual providers. An assignment account will be permitted only if the provider(s), as well as the entity to which payment is being directed, meet and continue to comply with the guidelines set forth below. The guidelines set forth below apply exclusively to payments under Highmark Blue Shield s health insurance products. These guidelines were developed to accommodate the needs of various business entities while at the same time, addressing Highmark Blue Shield s concerns regarding appropriate, efficient utilization of services and appropriate application of payment limitations for ineligible providers. II. Eligible Entities For the purpose of these guidelines, a provider will be considered to be a duly licensed health service doctor eligible for payment by Highmark Blue Shield. The following definitions clarify the perception of the various eligible entities. Use these definitions as a guideline to specify the type of legal entity on your application. Upon acceptable completion of the required forms, Highmark Blue Shield will permit an assignment account to be established for the following types of entities: A. Sole Proprietorship A sole proprietorship is unincorporated, owned by one individual, and its liabilities are the sole proprietor s personal liabilities. The sole proprietor takes the risks of the business for all assets owned. For legal and tax purposes, the business does not exist separately from the owner. B. Partnerships An organization that is unincorporated and has two or more members. The members carry on a business activity and are not considered employees. 1. General Partnership Consists of two or more people. Each partner is liable for all debts incurred on behalf of the partnership. Existence of the professional partnership may be demonstrated by a signed copy of the partnership agreement. 2. Limited Partnership This entity consists of one or more general partners and one or more limited partners. A certificate evidencing its formation is filed with the appropriate state. The general partner has personal liability for its debts and obligations. The limited partner can purchase an interest and be held liable for that interest; however, they have no personal liability beyond such interest. In cases in which the general partner of a limited partnership

4 is an eligible entity in accordance with these guidelines, an account may be established in the name of the general partner. Limited partners may not be included. For example, if the general partner of a limited partnership is a professional corporation, then the general partner s providers may establish an assignment account in favor of the professional corporation. The limited partners would not be members of the assignment account. 3. Limited Liability Partnership A limited liability partnership (LLP), subject to certain exceptions, provides partners protection from liability, direct and indirect, for debts and obligations of, or chargeable to, the partnership that arise from any negligent or wrongful acts or misconduct committed by another partner or other representative of the partnership. LLPs must register via a certificate and annually register with the appropriate state. The LLP and all members of the proposed assignment account who are licensed health service doctors will be required to execute an assignment account agreement. The members agree to be jointly and severally liable for overpayments and misreporting by the LLP and/or the members. C. Corporations Corporations consist of shareholders who exchange money, property, or both, for the corporation's capital stock. 1. Professional Corporation A Professional Corporation is a corporation which is organized for the purpose of engaging in a learned profession such as medicine. Professional corporations must file articles of incorporation with the state. One or more provider(s) may form a professional corporation in accordance with the Professional Corporation Law and the corporation becomes the employer of the provider(s). This would include solo practitioners who incorporate their practices. The Professional Corporation and all members of the proposed assignment account who are licensed health service doctors will be required to execute an assignment account agreement. The members agree to be jointly and severally liable for overpayments and misreporting by any and all partners to the account. 2. Nonprofit Corporations A Nonprofit Corporation is the corporation organized for other than profit making purposes. It may consist of members rather than shareholders. There may be constraints on the amount of income it can generate and use of its profits may be restricted. Highmark recognizes those established for the purpose of providing health care services through duly licensed health service doctors. The non-profit corporation, and all members of the proposed assignment account who are licensed health service doctors, will be required to execute an assignment account agreement. The members agree to be jointly and severally liable for overpayments and misreporting by or through the account. 3. Business Corporation These are sometimes referred to as a for-profit corporation. The business corporation must be established for the sole purpose of providing health care services, through duly licensed health service doctors. The entity may form an Assignment Account at the discretion of Highmark Blue Shield. The business corporation, and all members of the proposed assignment account who are licensed health service doctors, will be required to execute an agreement, agreeing to be jointly and severally liable for the overpayments and misreporting by or through the account. D. Limited Liability Company A limited liability company (LLC) provides limited liability to the LLC s members. LLCs are formed under state law by filing with the state as an LLC.

5 Unlike a partnership, none of the members of an LLC are personally liable for its debts. The LLC and all members of the proposed assignment account, who are licensed health service doctors, will be required to execute an assignment account agreement. The parties agree to be jointly and severally liable for overpayments and misreporting by or through the account. E. Health Care Facility Providers who are employed by or otherwise compensated by a health care facility (including, but not limited to, a hospital) or an affiliate of such health care facility (as defined below), for which Highmark Blue Shield has payment responsibility, may establish an assignment account on behalf of the facility to which they have assigned their right to bill, in the sole discretion of Highmark Blue Shield. These accounts are for the purpose of having fees for services paid by Highmark Blue Shield directed to the health care facility or its affiliate. It should be noted that, when established, such assignment accounts are solely for the purpose of directing professional fees which are otherwise payable under an individual or group benefit agreement or contract and which are otherwise not paid on a UB-92 claims form or through an alternative arrangement under the terms of an existing agreement that Highmark Blue Shield and/or its subsidiaries may have with the applicable facility and/or its affiliate. For purposes of the Section, an affiliate of a health care facility is a corporation which either controls, or is controlled by, the health care facility. Highmark reserves the right to request documentation confirming the legal status of the entity. This may be required to confirm eligibility status. III. Ineligible Arrangements The following arrangements are not eligible for an assignment account with Highmark Blue Shield: A. Corporate Practice of Medicine Prohibition Highmark Blue Shield will not permit an assignment account that would violate any applicable state prohibition on the corporate practice of medicine. B. Billing Agent Arrangements Highmark Blue Shield will not permit an assignment account where payments are made in the name and under a tax identification number of an entity or person that is merely the billing agent of provider. However, the provider may ask that payments be directed to a mailing address of a billing agent so long as the billing agent acts under a written agreement with the provider which the provider may modify or revoke at any time. C. Financing Arrangements Highmark Blue Shield will not permit an assignment account in order to direct payment(s) for the purpose of financing arrangements such as when a provider sells or pledges accounts receivable to a person or entity as collateral on a loan. D. Mixed Participating/Non-participating Provider Assignment Accounts A nonparticipating provider (meaning a provider nonparticipating in Highmark Blue Shield s Par Network) may not be included in a Highmark Blue Shield assignment account which also contains participating providers. E. Groups Seeking Solely to Purchase Services An assignment account may not be permitted in a situation which would effectively evade Highmark Blue Shield s purchased services

6 requirement. Highmark Blue Shield may not permit an assignment account to be formed in which the account intends solely to purchase professional services from independent contractors. F. Groups Established Solely as Investment Vehicles Assignment accounts are established for the purpose of permitting providers who practice together to bill under a single provider identification number. They will not be established in situations in which the apparent purpose of including members in the assignment account is to provide an investment vehicle for one or more other persons or entities not licensed to render the health care services offered by the providers in the assignment account. In a situation in which there is a question as to whether the account is being established for investment purposes, the proposed providers will be required to certify their intent to provide professional services on behalf of the assignment account. G. Groups Providing Non-covered Services In general, assignment accounts will not be permitted in situations where it is apparent that the majority of services to be provided will not be covered under Highmark Blue Shield contracts. However, Highmark Blue Shield, at its discretion, may establish such an account when necessary for its business purposes. H. Outstanding Utilization Review Issues Highmark Blue Shield will not permit an assignment account to be established in any situation in which any proposed member(s) of the assignment account has a pending utilization review issue with Highmark Blue Shield. Furthermore, Highmark Blue Shield will not permit the addition or deletion of members in any situation in which any of the members or the existing payee under assignment account have a pending utilization review case with Highmark Blue Shield. I. Groups Seeking Multiple Assignment Accounts Highmark Blue Shield reserves the right to refuse duplicate assignment accounts. Multiple accounts composed of the same providers, with the same tax identification number, practicing at the same office address will be refused. J. Mixed License Assignment Accounts In general, limited license providers may not be included in a Highmark Blue Shield assignment account which also contains health service doctors. Highmark Blue Shield has concluded that it will permit such an assignment account, since it would eliminate the ability to determine that a limited license provider reporting services is operating within the scope of his or her license. K. Other Business Entities Any and all legal entities or groups not included in Section II. may not be permitted by Highmark Blue Shield to establish an assignment account. L. Physician Assistant and Locum Tenens Physician Assistant and Locum Tenens do not fulfill the obligations of the Assignment Account. IV. Application Process A group of providers desiring to establish an assignment account must complete and submit an application form provided by Highmark Blue Shield. The following requirements apply to the application process (additional instructions are included on the form itself):

7 A. Each member of the group must provide his/her name, SSN, National Provider Identification number, specialty, signature and Highmark Blue Shield individual provider number. B. The group subject to the assignment account must provide its proposed tax identification number, a copy of their IRS notification and their National Provider Identification number. If a tax identification number of an entity other than the group making the application is to be used, the group must identify the entity whose number is being used. C. The group must provide a statement signed by each member who certifies that each member is billing fee-for-service and agrees to assign his or her fees to the group account. D. The group must agree to inform Highmark Blue Shield of any changes in the group s contractual arrangements that would necessitate Highmark Blue Shield payments being made to some entity other than that designated in the assignment account application. E. The group must agree that every claim submitted to Highmark Blue Shield will bear the name of the individual provider who actually performed the service(s). F. The group must agree to notify Highmark Blue Shield in writing of any subsequent changes in the membership of the assignment account prior to the effective date of each change. G. Each member of the group must sign a statement agreeing that the entity subject to the assignment account and each individual member will be jointly and severally liable for any overpayment that the entity receives. H. The group must provide a main practice address and telephone number that is accessible for Highmark business purposes and to Highmark members. A Post Office Box address is not acceptable. I. The application must contain the signature of the authorized representative of the group and a signature date. J. The applicant must specify if the group employs CRNAs, if the group is located in a hospital or hospital owned building, and if the group is billing under a tax ID number. Groups employing CRNAs must complete the supplemental CRNA Employment Status portion of the application (Attachment 1). K. Professional Provider Office Hours form must be completed and returned (Attachment 2). V. Termination Highmark Blue Shield reserves the right to immediately dissolve any assignment account in its sole discretion. The assignment account and its member providers shall be given written notice of a decision by Highmark Blue Shield to dissolve the account. Dissolution of an assignment account will not affect the right of the individual providers to submit claims under their individual provider members.

8 VI. Appeals Because it is impossible to address all possible billing and business arrangements in these guidelines, providers shall have the right to appeal Highmark Blue Shield s decision to deny an assignment account in any situation in which there is a question whether the group qualifies for the assignment account. Such appeal must be in writing. Proposed assignment accounts that do not strictly meet the eligibility criteria stated in these guidelines may be approved if it is established, to the satisfaction of Highmark Blue Shield, that the creation of the assignment account will significantly increase the delivery of high quality, cost effective health care to Highmark Blue Shield members. Such exceptions will only be granted in extraordinary circumstances; they are not a matter of course. Highmark Blue Shield reserves the right to deny any proposed assignment account that does not comply with all of the criteria set forth in these guidelines.

9 Request for Assignment Account Name of Account Specialty IRS # (Provide copy of Federal IRS Notification. W-9 is NOT acceptable.) Type 2 (Group) National Provider Identifier (NPI) Legal Entity Requesting Account (see Section II. Eligible Entities ) Please check one: Sole Proprietorship Partnership (General) Partnership (Limited) Non-Profit Corporation Business Corporation Professional Corporation Limited Liability Partnership Limited Liability Company (including restricted professional companies) Health Care Facility Other (explanation must be provided) Relationship Between Legal Entity and Provider Please check one: Employed Relationship Solo Practitioner General Partner Member/Shareholder Group billing under a Health Care Facility Tax ID Other (explanation must be provided) Main Practice Address Primary physical practice location (PO Box numbers are NOT acceptable) Telephone number: ( ) Fax number: ( ) Member Access Number: (Patients call this number to make an appointment for this location) ( ) Is this location in a hospital or hospital-owned building? Yes No Mailing Address where administrative work is done, if address different than Main Practice and Check: Check Address where checks are sent: Is this a lockbox? Yes No Telephone number: ( ) Telephone number: ( ) Fax number: ( ) Fax number: ( ) Does the group employ CRNAs? Yes No If YES, complete CRNA Employment Status (Attachment I). Do you currently participate in QualityBlue? Yes No If you are currently billing with another Assignment Account, will you be terminating that account? Yes No If so, when? (date) Name(s) of Providers in Assignment Account (type or print): Provider Name Highmark Provider # Social Security # Type I (Individual) NPI Specialty Signature* Each provider must sign to be enrolled in the group *By my signature, I, as a member of this account, fully agree to abide by the Assignment Account Agreements listed on the reverse side of this form S 07/08 (see reverse side)

10 Assignment Account Agreement 1. We hereby agree to only bill those services performed by providers in our account. 2. We certify that each member agrees to assign his/her fee to the group account. 3. We agree that every 1500 claim form submitted to Highmark Blue Shield will include the provider number of the individual provider who actually performed the service (place in Block 24K of the claim form). 4. We agree that the account and each individual provider member will be jointly and severally liable for any overpayment that the account receives. 5. We agree to notify Highmark Blue Shield in writing of any subsequent changes in the composition of the account prior to the effective date of each change. 6. We agree to inform Highmark Blue Shield of any change in the group s contractual arrangements that directly or indirectly impact this assignment account or that would necessitate Highmark Blue Shield payments to be made to some entity other than that designated in this assignment account application. 7. We certify that we will not bill for any professional services that are reimbursed through another Pennsylvania Blue Cross Plan. All claims for these services will be submitted on the 1500 claim form for all appropriate Blue lines of business patients. 8. We understand that for certain networks all individual providers in the group must be fully credentialed in order for the group to be able to bill for that network. 9. We have carefully reviewed the forms and applications associated with the establishment of this Assignment Account and each member has verified the accuracy and completeness of all information provided. 10. We have carefully reviewed the Assignment Account Guidelines and each member certifies and represents that the requested account will meet those guidelines, and when established, that the account will not represent an ineligible arrangement as described in Part III. of those guidelines. 11. We agree to be bound by the terms and conditions of either the KHPW Primary Care Physician Agreement or the KHPW Health Care Specialist Provider Agreement or both, or the KHPW Behavioral Health Care Specialist Provider Agreement, as applicable. We understand that individual KHPW providers must complete and receive approval of their credentialing application prior to rendering services to KHPW members. On behalf of the group, I verify that all providers have reviewed the Assignment Account Requirements, agree upon their responsibility, and recognize that as the authorized representative, I have the authority to bind the individual providers and sign on their behalf. Signature of Authorized Representative of Group Title Date ( ) Telephone Number

11 CRNA Employment Status Attachment 1 Page 1 of 2 Only health care professionals who have supplied the CRNA employment documentation and verified the employment relationship receive 100 percent of the approved allowance for covered services from Highmark Blue Shield when they medically direct (supervise) their employee. If this information is not on file with Highmark Blue Shield, reimbursement will be 50 percent of the approved allowance, in accordance with our existing policy. Health care professionals who employ CRNAs must provide sufficient documentation to establish an employer-employee relationship. This documentation can be in the form of the CRNAs W-2 Form and/or a copy of the contract between the health care professional and the CRNA, and a letter from the hospital administrator attesting to the billing arrangement. If you intend to submit claims for the services of CRNAs that you employ, please review the following criteria and respond as required: An employment relationship is established between the health care professional and nurse anesthetist if the following criteria are sufficiently documented: 1. The health care professional has the power to hire and fire the nurse anesthetist. 2. The health care professional has the power to direct the work performed by the nurse anesthetist and has ultimate responsibility for the manner of its performance. 3. The health care professional has the duty to pay wages, fringe benefits, and establish the level of compensation of the nurse anesthetist. 4. The health care professional is personally responsible for withholding federal income tax and Social Security contributions for the nurse anesthetist s compensation and is personally responsible for making contributions for the nurse anesthetist under the Pennsylvania Unemployment Compensation Act ( et. seq.) and is personally responsible for ensuring the nurse anesthetist s liability under the Pennsylvania Workmen s Compensation Act (77 1 et. seq.). 5. No hospital receives any compensation whatsoever for the services of the nurse anesthetist during the period the nurse anesthetist is employed by the health care professional. Please hold all claims for services for CRNAs you employ until advised by Highmark Blue Shield to start claim submissions. CRNA Employment documentation will need to be reverified on an annual basis. Failure to respond to a reverification request will result in reduced payments for anesthesia services. If the above criteria are met, please complete the form on the reverse and return it with the Assignment Account paperwork. Failure to respond will result in reduced payments for anesthesia services.

12 Attachment 1 Page 2 of 2 CRNA Employment Status Please complete and return this form with the CRNA employment documentation: Attached is the following documentation for review: W-2 Form(s) Contract Letter Other Listed below are the names and starting dates of employment for all CRNA employees. (If additional space is needed, please attach the additional names and dates.): Name License # Starting Date of Employment Name License # Starting Date of Employment Name License # Starting Date of Employment At what hospital(s) do you currently perform anesthesia services? List name(s) and address(es). Do you perform anesthesia services at a freestanding facility? Yes No If YES, who employs the CRNAs at the facility? Please complete the name(s) of the provider(s) and/or Assignment Account(s) and Highmark Blue Shield/provider number(s) you currently use to submit claims.

13 Attachment 2 Professional Provider Office Hours Form Group Name Type 2 (Group) National Provider Identifier Tax ID Below, please list the address for which office hours are being reported. Office hours are those times during which a patient will receive medical care. Do not include hours during which patients are not able to schedule appointments. Practice Location Address Make additional copies for each location (if needed). Telephone number: ( ) Fax number: ( ) Patient Access Number: (Patients can call Main Practice Location? this number to make an appointment for this location.) ( ) Yes No Office Hours Open Monday Tuesday Wednesday Thursday Friday Saturday Sunday Close Open Close Weekly Biweekly Monthly None

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