Navigating the Blues Training Guide

Transcription

1 Navigating the Blues Training Guide Basic Blues 101 Welcome to Navigating the Blues! Today s seminar will provide valuable information on Excellus BlueCross BlueShield, our products, authorization guidelines, ID cards and much, much more. Keep this guide at your desk as it contains information that can help you navigate the blues every day! 2016 Version

2 Table of Contents Basic Blues 101 Course 1 Company Overview Overview of Excellus BlueCross BlueShield Contact Us Daily Operations Course 1 Review Course 2 Product and Patient Information Types of Health Insurance Products Product Portfolio Individual Grace Period Consumer-Driven Health Plans ID Card Tips Course 2 Review Course 3 BlueCard Program Overview of BlueCard.3.1 Avoiding BlueCard Claim Issues, Delays and Rejections.3.2 Course 3 Review.3.3 Course 4 Medical Management Overview of Medical Management Referrals and Preauthorizations Course 4 Review Course 5 Pharmacy Benefit Management Medical Drug Benefit Medical Specialty Medication Prior Authorization Requirements Prescription Drug Benefit Course 5 Review Course 6 Working with Us Communications Access and Availability Credentialing and Recredentialing Website Forms 6.5 Course 6 Review

3 Course 1 Company Overview Overview of Excellus BlueCross BlueShield Contact Us Daily Operations Course 1 Review

4 Overview of Excellus BlueCross BlueShield 1.1 Excellus BlueCross BlueShield, headquartered in Rochester, NY, is part of a $6.6 billion family of companies that finances and delivers health care services across upstate New York and long term care insurance nationwide. Collectively, the enterprise provides health insurance to about 1.6 million members and employs about 6,000 New Yorkers. Central New York Region, based in Syracuse with an additional office in Watertown; Central New York Southern Tier Region, based in Elmira with an additional office in Binghamton; Rochester Region, based in Rochester; and Utica Region, based in Utica with additional offices in Oneonta and Plattsburgh. Rochester Region Livingston, Monroe, Ontario, Seneca, Wayne, Yates Central New York Region Cayuga, Cortland, Jefferson, Lewis, Onondaga, Oswego, St. Lawrence, Tompkins Central NY Southern Tier Region Broome, Chemung, Chenango, Schuyler, Steuben, Tioga Utica Region Clinton, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Madison, Montgomery, Oneida, Otsego 3

5 Contact Us 1.2 Need help? We are here for you! The following provides information on whom to contact at Excellus BCBS for a variety of different inquiries. When you return to your office, keep this information on hand for quick, easy reference. When to Contact Provider Relations vs Customer Care Customer Care: For questions regarding eligibility, benefits, claims and authorizations. Provider Relations: For questions regarding provider contracting, staff education and recurring issues. Contact Us - Grid Highlights Provider section of the Excellus BCBS Website: ExcellusBCBS.com/Provider Customer Care: Call with questions regarding eligibility, benefits, claims, remittances, checks Provider Relations Representative: Call for staff training/education and recurring issues. Access Contact and Territory and list at ExcellusBCBS.com/ProviderContactUs BlueCard Number for Out-of-Area Plans: Call to contact the member s home plan for benefits, referrals and authorizations Referrals & Preauthorization: Call to obtain a referral or preauthorizations evicore healthcare (formerly CareCore National) Preauthorization: Call for radiology preauthorizations Coordination of Benefits (COB): Questions when a patient has two or more insurance policies ecommerce: Call for questions on electronic billing, clearinghouse questions, etc. Web Help Desk: Call if you are having issues with our website 1099 Support: Call with questions regarding 1099 forms or 1099 information Credentialing: Call for questions regarding credentialing Provider File Maintenance: To update provider information, use online form or fax/mail form ExcellusBCBS.com/ProviderUpdateInfo. Claim Submission Address: Excellus BlueCross BlueShield, PO Box 22999, Rochester, NY

6 Contact Grid Name Comments Telephone No. Fax No. Excellus BlueCross BlueShield online ExcellusBCBS.com/Provider This website allows you to check member eligibility, verify benefits, check claim status and request preauthorization. Also, you can learn about member health benefit program requirements, along with many other options that are available when you register for online access. Customer Care is available Monday through Thursday, 8 a.m. - 5:30 p.m., Fridays 9 a.m. to 5:30 p.m. Registration can be completed online. Review a member s eligibility for benefits. Check claim status. Update practice information. Request a claim adjustment. Enter referrals. Request a preauthorization. View fee schedule information. Review clinical editing. View pharmacy information. View medical and administrative policies. Compare hospital quality information. Customer Care All Excellus BlueCross BlueShield Regions Customer Care, Medicaid Managed Care Customer Care, Direct Vision Line Accredo Pharmacy, specialty pharmacy for patient-administered and provider-administered medications 1099 Support Unit Behavioral Health Preauthorizations Questions about claims, member benefits and eligibility, etc. Child Health Plus Blue Choice Option/HMOBlue Option Premier Option Questions about vision claims, member benefits and eligibility, etc. Patient-administered Provider-administered Questions regarding W-9 forms or 1099 information Mental health/psychiatric hospitalization, inpatient chemical dependency, outpatient mental health (select products only), and psychological evaluation Rochester, CNY S.Tier Regions CNY and Utica Regions Inpatient Services Inpatient Substance Use Admissions Outpatient Services HMOBlue Option and CHP

7 Contact Grid Name Comments Telephone No. Fax No. BlueCard BlueExchange (Web-based) CAQH (Council for Affordable Quality Healthcare) Case Management (Commercial Products) Member Care Management Chronic Care Management Information on members from out-of-area BCBS health plans Inquiries regarding claim status (from your telephone key pad, select 2 for claims) Registration required for use. Providers may register directly from the website. For practitioner credentialing To make referrals Case and Disease Management, Government Programs Care Management, Behavioral Health (Commercial Products) To refer members of Child Health Plus, HMOBlue Option, Blue Choice Option or Premier Option for case management To make a referral, call Monday through Thursday, from 8 a.m. to 5 p.m. and Friday from 9 a.m. to 5 p.m. If you call after-hours, leave a message on the confidential voice mail and your call will be returned the next business day. CNY Utica Region Rochester Region Claim Status Call Customer Care or use the website (registration required) Claims Submission, Electronic See ecommerce below Claims Submission, Paper CompassionNet Excellus BlueCross BlueShield PO Box Rochester, NY Case management for children with life-threatening illnesses Computer Sciences Corporation (CSC) (epaces Medicaid eligibility inquiries) Institutional (Clinics, hospitals, etc.) Practitioner (MDs, Dentists) Professional (DME, non-mds) Credentialing, Central New York, CNY So. Tier and Utica Regions (credentialing questions only) Credentialing, Rochester Region (credentialing questions only) New applicants Recredentialing New applicants Reappointments (A-K) Reappointments (L-Z)

8 Contact Grid Name Comments Telephone No. Fax No. Credit and Collection (address to return overpayments) Excellus BlueCross BlueShield Credit and Collection 333 Butternut Drive Syracuse, NY Departmental Appeals Board (HHS) (Medicare Advantage only) Disease Management Member Care Management Complex Care Management (Commercial products) ecommerce epaces (software for Medicaid eligibility inquiries) Fair Hearing (Medicaid managed care) Department of Health & Human Services Departmental Appeals Board, MS 6127 Medicare Appeals Council Cohen Building, Room G Independence Avenue, SW Washington, DC To refer a member for case management Electronic transactions including claim submittal and electronic remits New York State Office of Temporary and Disability Assistance Office of Administrative Hearing Unit Managed Care Hearing Unit PO Box Albany, NY Call Computer Sciences Corp Federal Employee Program (FEP) Health Coaching (24/7 Nurse Call Line) Member ID number prefix is the letter R Free program (available 24/7) for members in selected plans to call for information about chronic conditions and other health-related information TTY Help Desk Resetting log in and passwords CNY & CNYST Rochester Utica HIV Counseling & Testing NYSDOH Program AIDS InfoCheck (Rochester Region only) Phone line available 24/7 except 5-6 a.m., M-Fri and Sunday midnight until 6 a.m. Monday Livanta May be used to check eligibility, benefits, referrals and claim status for managed care. Requires Provider NPI Medicare Appeals TTY

9 Contact Grid Name Comments Telephone No. Fax No. Medical Intake Most referrals and prior authorizations Medical Policy Coordinator Medical Specialty Medication Review Program Medicare Advantage Coding Review Questions and comments on medical policies. To request prior authorization forms and specialty pharmacy information. Excellus BlueCross BlueShield Revenue Integrity Department 165 Court St. Rochester, NY Call Customer Care Member Eligibility Member Grievances Call Customer Care, or use the website (registration required) During regular business hours, call or visit Customer Care for the applicable program. National Provider Identifier (NPI) Enumerator TTY PCP Selection Form (safety net members) Fax form for safety net care members to select or change PCP Pharmacy Help Desk Questions, exceptions, prior authorizations Preauthorization Most services that require preauthorization. Inpatient or Outpatient. Request via Clear Coverage Web tool online at: ExcellusBCBS.com/Provider After-hours line (for all regions): Inpatient (for all regions): Outpatient (for all regions): Preauthorization, Imaging Studies (CT, MRI, MRA, PET, nuclear cardiology) evicore healthcare (formally CareCore National) Requests may be made via Web, fax or phone. Special form required for faxed requests. Web access from the Excellus BlueCross BlueShield website: ExcellusBCBS.com/Provider M-F: 7 a.m. 7 p.m

10 Contact Grid Name Comments Telephone No. Fax No. Privacy Questions and Complaints Provider Advocate Unit Provider File Maintenance For information about our privacy practices or concerns: For privacy rights or questions: Privacy complaints: Call, mail or Mailing address: Privacy Officer 333 Butternut Drive Dewitt, NY PO Box 4717 Syracuse, NY To update provider information, use our online form or fax/mail form. In addition, you can send us changes by mail or fax using your company letterhead. ExcellusBCBS.com/ProviderUpdateInfo Call Customer Care or Provider Relations CNY, CNYST & Utica Rochester Provider Relations Quit For Life Referrals (May also use Web to request referrals) Specialty Pharmacy Sterilization and Hysterectomy Consent Forms (Medicaid managed care) Taxonomy (to select appropriate taxonomy) List of PR representatives on the website, ExcellusBCBS.com/ProviderContactUs, or contact Customer Care. Smoking cessation program for eligible members. Representatives available M to Th., 8 a.m. to 5 p.m., F, 9 a.m. to 5 p.m. See Accredo and Walgreens To request patient consent forms for sterilization or hysterectomy. Via Web: To view a complete list of taxonomy codes, go to the following website: wpc-edi.com/reference/ Vaccines for Children Program Medicaid managed care (HMOBlue Option & BlueChoice Option) and Child Health Plus only Walgreens Specialty Pharmacy, for patientadministered and provideradministered medications vaccines_for_children.htm Patient-administered Provider-administered Web Security Help Desk M to Th, 8 a.m. to 4:30 p.m. F, 9 a.m. to 4:30 p.m (end) 9

11 Daily Operations 1.3 Use the following information as a quick reference for daily operational procedures at your office! We recommend posting this information at your desk for quick access. Daily Operation Question Where can I verify patient coverage/eligibility/benefits? Is referral/preauthorization needed for a service? Is there a referral on file? Do we participate with this plan? Where should I go for questions about filing claims? How can I check claim status? How can I request an adjustment? I would like to bill electronically? How do I get started? Where can I obtain your medical policies? Are there programs for patients with chronic conditions? Where can I find an alpha prefix listing? How do I update my practice information? Reference Tools Available Visit the Website, Call Customer Care Visit the Website, Call Customer Care Visit the Website*, Call Customer Care Visit the Website*, Call Customer Care, Reference the Online Provider Directory, Call Provider Relations Call Customer Care Visit the Website*, Call Customer Care Visit the Website*, Call Customer Care, Access the Request for Adjustment form Call ecommerce Visit the Website*, Call Customer Care, Review the Connection newsletter Visit the Website*, Call Customer Care, Reference the Provider Manual Visit the Website*, Call Customer Care Visit the Website*, Call Customer Care Website: ExcellusBCBS.com/Provider See the Click Before You Call flyer in Course 6 of this training guide for specific website locations. *Web tool resides in an area of the Excellus BCBS website that requires login. Customer Care:

12 Course 1 Review 1.5 Answer the questions below based on what you learned in Course In which Excellus BCBS region is your office or facility located? 2. What is considered your Local BCBS plan? 3. Whom would you call in the following situations? Select either Customer Care or Provider Relations representative. a) To find out if a provider participates with a specific product? b) To verify a member s coverage? c) To check to see if a referral has been done? d) To check to see if Excellus BCBS received medical records? e) Questions regarding the provider s contract? f) Problems with a continual issue with no resolution? 11

13 Course 2 Product and Patient Information Types of Health Insurance Products Product Portfolio Individual Grace Period Consumer-Driven Health Plans ID Card Tips Course 2 Review

14 Types of Health Insurance Products 2.1 Health Insurance Products Excellus BCBS offers its members various kinds of health care coverage. Products offered to members can differ by region. You can verify your patient s participation status, or a patient s eligibility/benefits, by checking our website, ExcellusBCBS.com/Provider, or by calling Customer Care. A product is the type of health insurance contract (i.e., health insurance coverage) between a health plan and a member. Take a look at the grid on the following pages for information on the products we offer. Please note that the grid is subject to change as new products are developed, or when products discontinue. To access the most current product portfolio online, visit the Education section of our website at ExcellusBCBS.com/ProviderEducation. 13

15 Product Portfolio 2.2 Our individual, small and large group products are developed to comply with the Affordable Care Act. All products can be purchased directly through Excellus BCBS or select individual and small group plans can be purchased through the NYSOH Marketplace. Product Classifications Product referred to as: HMO (Health Maintenance Organization) for Employer Groups Managed care product. Primary care provider (PCP), referrals and preauthorizations may be required Must use participating (in-network) providers. Provides comprehensive benefits, including coverage for routine/preventive care for children and adults. First dollar coverage through copayments and/or coinsurance (no deductibles). Multiple copayment options available. Blue Choice 30 Copay Option (Rochester) Blue Choice 25 Copay Option (Rochester) HMOBlue 25 (CNY, So. Tier & Utica) HMOBlue 30 (CNY, So. Tier & Utica) Excellus BCBS HMO POS (Point-of-Service) for Employer Groups Provides in and out-of-network coverage. PCP and preauthorization may be required for highest level of coverage (similar to HMO). Member decides at point of service whether to coordinate care through PCP. If the member chooses not to coordinate care, there is increased cost-sharing for out-ofnetwork coverage. First dollar in-network coverage through copayments and/or coinsurance (no deductibles). PPO (Preferred Provider Organization) for Employer Groups No PCP required. Some services require precertification or preauthorization.* In-network and out-of-network coverage. In-network participating providers must be used. Out-of-network non-participating providers may be used, but higher costsharing may apply. Typically, deductible must be met, then copayment/coinsurance. Multiple copayment, coinsurance and deductible options available, providing a range of benefit levels from which to choose. *Preauthorization requirements mirror those of HMO products BluePoint 2 BluePoint 3 Copay & Copay & Deductible Plans (Hybrids) Excellus BluePPO BluePreferred PPO (CNY, So. Tier & Utica) HealthyBlue* SimplyBlue* SimplyBlue Plus High-Deductible Health Plan (HDHP) Health Savings Account Qualified Plans (HSA) Excellus BluePPO HealthyBlue HDHP* SimplyBlue HDHP* SimplyBlue Plus HDHP* 14

16 Product Classifications Product referred to as: EPO (Exclusive Provider Organization) for Employer Groups No PCP required. Some services require precertification or preauthorization. In-network coverage only, and in-network providers must be used. Out-of-network services not covered. Typically, deductible must be met, then copayment/coinsurance. Multiple copayment/coinsurance and deductible options available, providing a range of benefit levels from which to choose. EPO (Exclusive Provider Organization) for Direct Pay Members No PCP required. Some services require preauthorization or precertification*. In-network coverage only, and in-network providers must be used. Out-of-network services not covered. Typically, deductible must be met, then copayment/coinsurance. Multiple copayment, coinsurance and deductible options available, providing a range of benefit levels from which to choose. Premium assistance may be available for those who qualify. Must apply through +Lower cost share options available to those who qualify. *Preauthorization/precertification requirements for Direct Pay Metal Plans mirror those of our HMO products. **Native American plans and Silver cost-share reduction plans do not qualify for a health savings account. Excellus Blue EPO Copay and Copay & Deductible Plans (or Hybrid plan) Platinum Standard Platinum Select Gold Standard Gold Select Silver Standard+ Bronze Standard Base Bassett Gold & Silver Select (Delaware, Herkimer & Oneida, Otsego counties only) CNY Preferred Gold (Onondaga & Lewis counties only) Indemnity for Employer Groups No PCP required. Some groups may require preauthorizations. Deductible must be met first, and then coinsurance applies. Comprehensive (hospital, physician, ancillary) coverage. Typically includes an out-of-pocket maximum. Prescription coverage (if included) is generally the same as the medical deductible, then coinsurance or copayment. Participating providers accept our payment plus member cost-sharing as payment in full. Some services not covered if rendered by non-participating provider. Medicare Supplements Pays after Medicare. Government-structured benefit package. High-Deductible Health Plan (HDHP) Health Savings Account Qualified Plans (HSA) Silver Select** Bronze Standard HSA** Bronze Select** Classic Blue Traditional Classic Blue Secure (over 65 retiree plan) Medicare Supplements (see separate section) Medicare Supplemental 15

17 Product Classifications Medicare Advantage Providers submit claims directly to Excellus BCBS. Excellus BCBS pays as primary. Includes all Medicare benefits, plus preventive care and other value-added benefits. Highest level of benefit for services from participating providers. PCP and referrals required for HMO and HMO-POS products. Precertification requirements. To qualify, members must have Medicare Parts A and B, and not be in treatment for end-stage renal disease (ESRD). Product referred to as: Medicare Blue Choice HMO (Rochester) Medicare Blue PPO Medicare Bassett HMO-POS* (Herkimer, Delaware & Otsego counties) * This product does not require referrals; however, a PCP is required. New York State Government Programs New York State programs administered by Excellus BCBS in approved counties. Comprehensive (hospital, physician, ancillary) coverage. Specific eligibility and income requirements. PCP required. Referrals and/or preauthorizations may be required. *Enrollment Assistants or Community IPA/Navigators are available to help prospective members with eligibility and enrollment. Healthy NY EPO Child Health Plus* HMOBlue Option* (CNY, So. Tier & Utica) Blue Choice Option* (Rochester) Essential Plan We offer Tiered Network plans in select counties to Individual Direct Pay Members. They are referred to as: Bassett Gold Select & Bassett Silver Select - Available in Delaware, Herkimer and Otsego counties only CNY Preferred Gold Available in Onondaga and Lewis counties only These plans offer Tier 1 and Tier 2 coverage. Here is how they work: Tier 1 (Preferred Network): Our members who are enrolled in preferred network plans pay less out of pocket when they go to a Preferred Network provider or facility. In order for the lower cost share to apply, they must see a provider in this preferred network. The value to the member is lowest out-of-pocket costs when the preferred network is used. There is no coverage for care at a non-par (out-of-network) provider or facility for any services except for emergency care and dialysis. Tier 2 (Non-Preferred Network): Our members who are enrolled in non-preferred network plans have access to the larger network. Members may also use the Excellus BCBS EPO/PPO network in our 31-county service area. However, if they go to a provider outside of the preferred network, they will pay more out-of-pocket. The value to the member is access to larger network, but the member will pay more to use the non-preferred network. There is no coverage for care at a non-par (out-of-network) provider or facility for any services except for emergency care and dialysis. 16

18 On-exchange product prefixes: YNE = Individual YNB = Individual Bassett YNC = Essential Plan YNS = Small Group YNG = Individual CNY Preferred ID cards will have a suitcase with a B, if the product is offered on the NY State of Health. Off-exchange product prefixes: YNI = Individual YNL = Individual Bassett YND = Small Group YNH = Small Group HMO VYH = Small Group Healthy New York EPO YNJ = CNY Preferred 17

19 Individual Grace Period 2.3 Individuals who purchase coverage through the NY State of Health and receive an advance premium tax credit have a 3-month grace period to pay his or her premiums. The member must have paid the first month s premium before the 3-month grace period begins. During the first month, health plans are required to pay claims. During the second and third months, if the member fails to pay his or her premium, claims will pend for nonpayment. If entire premium has not been paid by the end of the grace period, all claims for services incurred during the second and third months of the grace period will deny. The law states that health plans: May pend claims during the 2 nd and 3 rd month of the grace period, and that they must notify IRS/HHS after the first delinquent month of nonpayment of premium. In addition, they must notify: Providers of the possibility for denied claims during the second and third months of the grace period. Members when payment is late and if coverage is terminated. Checking Member Grace Period Status Online via ExcellusBCBS.com/Provider: 18

20 Checking BlueCard Member Grace Period Status via BlueExchange 19

21 Consumer-Driven Health Plans 2.4 Consumer-driven health plans continue to grow in popularity, and along with these types of plans comes a new type of patient one who is encouraged to improve his or her own health and take control of personal health care decisions and expenses in collaboration with his or her provider. Your office or facility has likely seen an increase in patients with this type of coverage, and you re likely to see even more in the coming years. Therefore, it is important to know how these plans work and how to manage patient-toprovider payment. Consumer-driven health plans consist of three main components: 1) affordable high-deductible health plans 2) a funding account such as a health savings account, health reimbursement account, or a flexible spending account 3) access to online health information, tools and resources. Patients pay out-of-pocket for services until their deductible is met. This excludes preventive services that are covered-in-full (for most groups). The patient is responsible for paying a deductible up to a certain amount. The amount the patient will have to pay for his or her deductible depends on his or her plan. Providers may bill the patient at the time of service, if the deductible has not been met. After the deductible is met, the patient will pay a percentage of cost, called coinsurance. See the example below for details. 20

22 Patients with High-Deductible Health Plans Payment Collection Steps to Take: Inform the patient of your policy regarding collection of payment at the time of service. Confirm the status of the deductible by visiting the Excellus BCBS website: ExcellusBCBS.com/ProviderCoverageClaims > Deductible & Cost Sharing Keep a list of our allowances and if the patient has not met his or her deductible, collect the allowed amount at the time of service based upon CPT code. Physicians may obtain our schedule of allowances via the secure section of our website. Log in and password is required. For other health care professionals, each December, we mail you an annual fee schedule notice that contains a schedule of allowance for the most commonly billed codes for your specialty. If you have questions or need additional information about our schedule of allowances, please contact your Provider Relations Representative. Always submit a claim, regardless of the patient s status in meeting his or her deductible. If your office or facility requires payment at the time of service, and it s determined on the remittance invoice that too much was collected, you are required by law to promptly refund the difference to the patient. Office Notepad To assist your office with payment collection, Excellus BCBS has developed a Consumerdriven Health Care Provider Office Notepad (sample to right), which explains to the member that cost-sharing may be required at time of service if his or her deductible is not yet met. We recommend placing these pads in your waiting room and at your reception area. If you would like a supply, order online at ExcellusBCBS.com/Provider > Print Forms > Brochures > Order Free Preprinted Patient Brochures and Supplies. Complete the form and mail or fax it to the address/fax number indicated. If you would like education and training for your office on consumer-driven health plans, contact your Provider Relations Representative. You can also visit our website, ExcellusBCBS.com/Member/CDHC, for additional information about these plans. 21

23 ID Card Tips 2.5 Identification cards carry vital information to assist you in submitting clean claims. At every visit, be sure to: 1) Make a copy of your patient s ID card (front and back). 2) Verify the card s information against the member s eligibility and benefit information on our website, ExcellusBCBS.com/Provider. Keep the following in mind when reviewing patients ID cards: Logo: BlueCross BlueShield logo is located on all BCBS plan ID cards. Subscriber Name: Name of the person holding the policy. Is there a new policyholder? Is your patient on the subscriber s policy? You can verify this information at ExcellusBCBS.com/Provider. Identification Number: Numbers will have a three-character prefix that is vital to the correct processing of your claims. Copay Amount(s): Collect copays from the patient at the time of service. Provider or Primary Care Physician (PCP): PCP information is only listed on ID cards for members enrolled in the following HMO products: Child Health Plus and Medicare HMO cards. For HMO members, OB/GYN information will be listed when applicable and available. Dependent Information: Dependents will not be listed on the card. This information will be provided on a separate cover sheet that will be included when the member is issued his/her ID card. Dependent information can be verified at ExcellusBCBS.com/Provider. Telephone Numbers/Instructions: The telephone numbers for Customer Care and for preauthorization are located on the back of the card. If you have questions regarding a member s benefits, please do not hesitate to call for assistance. The ID card is a sample only. Subscriber ID cards vary by product type. Front of Card Back of Card Product Name 22

24 Mobile ID Cards Using this mobile-friendly feature, members can quickly and conveniently access their subscriber ID card and account statements anytime, anywhere! If a member uses his or her mobile ID card, please be aware that mobile ID cards displays just like a hard copy of the ID card. See sample below. 23

25 Helpful Hints: It is important to enter information exactly as it appears on the ID card. However, when a hyphen appears in the Information You Should Gather from Patients: identification number, drop the hyphen and the last number from your entry. Nicknames and special characters (e.g., hyphens) are not acceptable. Patient Name Patient DOB Patient Sex Make sure your office staff knows what products you participate with. This will allow your staff to recognize ID cards from those with whom you do not participate. Patient Address Patient s type of product or insurance Remember, if you are participating in a national provider network, you may be rendering services to out-of-area patients. Please send claims for these services to your local plan for submission through BlueCard. Check Eligibility and Benefits Online! Verify the information found on the member s ID card via the Excellus BCBS website, ExcellusBCBS.com/ProviderCoverageClaims. Your Provider Relations representative is always available for hands-on website training! 24

26 Course 2 Review 2.6 Answer the questions below based on what you learned in Course Name some products offered by Excellus BCBS. 2. How can you tell if a product is On-exchange? 3. What is a hybrid health insurance plan? 4. Individuals who purchase coverage through the NY State of Health and receive an advance premium tax credit have a 3-month grace period to pay his or her premiums. Where can you check the status of a member s grace period? 5. Name the basic elements of an ID card. 6. If a member presents a mobile ID card can they you his or her ID card information? Yes or no? 7. What information is on the front of the ID card? 8. What information is on the back of the ID card? 9. Can you find member benefit and eligibility information via our website? 10. What is a consumer-driven health plan? 25

27 Overview of BlueCard.3.1 Course 3 BlueCard Program Avoiding BlueCard Claim Issues, Delays and Rejections.3.2 Course 3 Review

28 Overview of BlueCard 3.1 BlueCard is a program unique to BlueCross BlueShield Plans nationwide. Look for the suitcase logo located on the patient s identification card. This symbol represents the BlueCard program. BlueCard Terms A Home Plan is the plan in which the patient is enrolled. A Host Plan (local plan) is the plan in the area where the services are rendered. BlueCard Rules If you participate with your local BCBS plan for indemnity, PPO, EPO and POS products, you are also a participating provider for out-of-area BCBS members with these products. For managed care plans, an out-of-area authorization must be obtained from the member s plan in order for services to be covered (except for emergencies). Workers Compensation and No Fault claims cannot go through BlueCard. For those claims, you must work directly with the patient s Home Plan. Submit all other claims to your local BCBS plan just as you would submit claims for locally enrolled subscribers. BlueCard claims must be billed with the three-letter alpha prefix. The letters in the prefix indicate the patient s Home Plan. Medicare Advantage PPO Medicare Advantage PPO network allows members to obtain in-network benefits when traveling or living in a service area of any other BCBS Medicare Advantage PPO Plan Members are extended the same contractual access to care Providers are reimbursed in accordance with their Excellus BCBS contract An MA will be noted in the suitcase on the member s PPO ID card. This indicates that the member is covered under the Medicare Advantage PPO network sharing program 27

29 Member Identification BCBS plans are sensitive to member concerns about identity theft and support legislative efforts toward protecting members privacy. In recent years, BCBS plans have replaced Social Security numbers on member ID cards with an alternate, unique identifier. The new identifier begins with the three-character alpha prefix, which identifies the member s Blue plan and is critical for eligibility/benefits verification and claims processing; this may be followed by up to 14 more characters in any combination of letters and numbers. Although the majority of member ID numbers still use only nine characters following the alpha prefix, some numbers will be shorter and some will be longer. As a provider servicing out-of-area members, you may find the following tips helpful: Ask the member for the most current ID card at every visit. Since new ID cards may be issued to members throughout the year, this will ensure that you have the most current information in your patient s file. Verify that the ID number on the card is not his/her Social Security number. If it is, call the BlueCard Eligibility line at BLUE to verify the ID number. Make copies of the front and back of the member s ID card and pass this key information on to your billing staff. When filing the claim, always enter the ID number exactly as it appears on the patient s card, including the three-character alpha prefix. Nicknames and special characters (e.g., hyphens) are not acceptable. The member ID will always include the alpha prefix in the first three positions. The alpha prefix must be included as part of the member ID number on the claim. Following the three-character alpha prefix, the ID number may include any combination of letters or numbers up to a maximum length of 17 characters total. This means that you may see cards with ID numbers between six and 14 numbers/letters following the alpha prefix. Examples of ID Numbers ABC ABC1234H567 ABC Alpha Prefix Alpha Prefix Alpha Prefix 28

30 When to Contact your Home Plan and Local Plan: Contact the Home Plan for: Membership Benefits Referrals and Authorizations There are two ways to contact the Home Plan: 1. Access BlueExchange via ExcellusBCBS.com/ProviderCoverageClaims. 2. Call the BlueCard 1-800# network: Dial BLUE (2583). Provide the alpha prefix from the ID card. Your call will be routed to the member s Home Plan. Contact your Local Plan for Claim Inquires ONLY: There are three options for claim inquiries: 1. Access BlueExchange via ExcellusBCBS.com/ProviderCoverageClaims. 2. Use the paper adjustment form provided by Excellus BCBS; or 3. Call Customer Care. 29

31 Avoiding BlueCard Claim Issues, Delays and Rejections 3.2 To help avoid delays, follow these simple steps: 1. Copy: Make copies of the front and back of the member s ID card and pass this key information on to your billing staff. Be sure that the member has the most current ID card. Quick Tip When you re referring a patient or a patient s information to a provider where there is not a face-to-face encounter, please include copies of the patient s ID card and the patient s complete ID number, which includes the alpha prefix. 2. Look: Find the three-character alpha prefix. For BlueCard, the alpha prefix identifies the member s Blue Plan or national account. It s also critical for confirming membership and coverage. 3. Contact: Once you ve identified the alpha prefix, call BlueCard Eligibility at BLUE (2583) to verify the member s eligibility and coverage. 4. Submit: After you include all the necessary information; submit the claim to Excellus BCBS. Also, make sure you price the claim according to your contract with Excellus. To ensure that your claims are processed timely and accurately, follow these steps: 1. Submit all Blue claims to Excellus BCBS. 2. Include the member s complete identification number, including the three-character alpha prefix, when you submit the claim. Claims with incorrect or missing alpha prefixes and/or member identification numbers cannot be processed. 3. In cases where there is more than one payer and a Blue Cross and/or Blue Shield Plan is a primary payer, submit Other Party Liability information with the Blue Cross and/or Blue Shield claim. Upon receipt, Excellus BCBS will electronically route the claim to the member s Blue Plan. The member s Plan then processes the claim and approves payment; Excellus BCBS will reimburse you for services. 4. Do not send duplicate claims. Sending another claim, or having your billing agency resubmit claims automatically, slows down the claims payment process and creates confusion for the member. 5. Check claim status online at ExcellusBCBS.com/ProviderCoverageClaims. If you encounter an issue with a claim, a Customer Care advocate will work with you to resolve the issue as quickly as possible. 30

32 Blue-branded Visa Debit Cards When rendering services to other Blues plan members, you also may see Blue-branded Visa debit cards, as well as other banks MasterCard debit cards. How they work: Debit cards can be used to pay for copayments, deductibles and coinsurance. You should verify the member s cost-sharing amount before payment. In most cases, when the out-of-pocket responsibility is a copayment, the member will not have to provide documentation to validate the expense. Simply swipe the card through a Credit Card terminal device. For either debit card, if a transaction is not authorized due to insufficient funds: Collect the full amount of the member s responsibility directly from the member, or Accept partial payment from the funds remaining in the member s account and collect the balance directly from the member. Questions about the debit card should be directed to the number listed on the card. 31

33 Course 3 Review 3.3 Answer the questions below based on what you learned in Course What is the name of the unique program linking BCBS plans across the nation? 2. What is the indicator on a patient s ID card for the above program? 3. Where should you submit claims for an out-of-area BCBS member? 4. What is the term used for the plan in which the member is enrolled? 5. What is the term used for the plan where services or provider are located? 6. What is imperative for all BlueCard claims to determine the patient s home plan? 7. What are the two ways to verify an out-of-area member s eligibility? 32

34 Course 4 Medical Management Overview of Medical Management Referrals and Preauthorizations Course 4 Review

35 Overview of Medical Management 4.1 Introduction to Medical Management Providers who agree to participate with Excellus BCBS have also agreed to cooperate in and comply with the standards and requirements of Excellus BCBS s utilization management (and other) initiatives. Excellus BCBS conducts utilization review to determine whether health care services that have been provided, are being provided, or are proposed to be provided to a member are medically necessary. Excellus BCBS has a medical policy defining Medically Necessary Services. The policy is available on our website or from Customer Care. Medical Management guidelines apply to managed care or gatekeeper products. In addition, preauthorizations may apply to some PPO products, for example, Medicare Blue PPO. A primary care physician is responsible for coordinating the member s care for managed care products. Remember to identify managed care members by the product type listed or by utilizing our website to verify their PCP. There are three sections to Medical Management: Referrals, Preauthorizations and the Outpatient Procedure list, you can find these lists on our website at ExcellusBCBS.com/ProviderReferralsAuths. Information on preauthorization requirements for pharmacy benefits (medical and prescription drugs) are not included in this course. You may find them in Pharmacy Benefit Management course. Medical management requirements are different for commercial managed care products vs. government programs. This is clearly identified on the grids found later in this course. 34

36 Referrals and Preauthorizations 4.2 Referral: A request for managed care patients to see a specialist in an office setting. The PCP is responsible for requesting approval from Excellus BCBS for referrals. Specialties that require referrals are listed in our referral guidelines, which are posted to our website. There are a very limited number of referrals needed for Excellus BCBS products. Preauthorizations: A request for a specific procedure/service (such as physical therapy or CT scan). We require that all preauthorizations for hip and knee replacement services, bariatric surgery, hysterectomy, tonsillectomy, physical therapy, occupational therapy, speech therapy and home care services be requested through our Clear Coverage electronic preauthorization system. For in-office training on Clear Coverage, contact your Provider Relations Representative. You can also access our Clear Coverage Resource Guide and Tip Sheets via the Education section of our website. Preauthorizations have a beginning and an end date. In some cases, they are limited to a specific number of visits. Services that require preauthorization are listed website, ExcellusBCBS.com/ProviderReferralsAuths. Preauthorizations need to be obtained by the ordering physician. If the ordering physician is a specialist, a valid referral must be on file to that specialist, before preauthoization for a service can be obtained. Preauthorizations for radiology, sleep management and implantable cardiac devices are obtained through evicore healthcare (formerly CareCore National). Outpatient Procedure List: A number of services have been classified as most appropriate when rendered in an outpatient setting, based primarily on previous year s InterQual guidelines. If these procedures are performed inpatient, a preauthorization is required. For Medicare inpatient guidelines, visit the CMS website, for the most current Medicare inpatient list. 35

37 Requesting Referrals and Preauthorizations Excellus BCBS: Access our Clear Coverage authorization tool via our website, ExcellusBCBS.com/ProviderReferralsAuths Obtain referrals/authorizations by telephone Excellus BCBS Safety Net Lines of Business: We are excited to announce our partnership with Centene Health Systems Group of New York Inc., an affiliate of Centene Corporation ( Centene ), to provide administrative support for our Safety Net (Child Health Plus, HMOBlue Option, Blue Choice Option, Premier Option and Premier Child Health Plus) products. Centene is nationally distinguished for providing health care programs and related services to underinsured and uninsured individuals. Centene will open an office and hire staff in Rochester, N.Y., as part of its commitment to the importance of local delivery of care. Pending approval by the New York State Department of Health, effective January 1, 2016, Centene willbegin to administer a limited number of disease management cases, and we are targeting an April 1, 2016, launch for Centene to administer integrated member care that includes full disease management, member case management, some utilization management functions and specified quality management initiatives for our Safety Net members. Our health plan will continue to work with you on all other business processes. Additional information about the processes Centene will manage will be provided in our annual Utilization Management Update notice, and we will continue to keep you current on details of these processes in the coming months. BlueCard : Contact the Home Plan: Access BlueExchange via ExcellusBCBS.com/Provider, or Call the BlueCard network: Dial BLUE (2583) Use Electronic Provider Access - Gives providers the ability to access out-of-area member s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review. The term pre-service review is used to refer to pre-notification, pre-certification, preauthorization and prior approval and other pre-claim processes. Access this tool by visiting, the Referrals & Auths section of our website. evicore Healthcare: Contact evicore Healthcare for radiology, sleep management and implantable cardiac devices preauthorizations Telephone: Fax Number:

38 Website accessed via ExcellusBCBS.com/ProviderReferralsAuths ProgenyHealth, Inc. Neonatal Intensive Care: Neonatal Intensive Care program in partnership with Progeny for Safety Net lines and commercial lines of business. When a member with Safety Net or commercial coverage is admitted to a NICU or special care nursery, authorization must be obtained by the facility regardless of whether the mother s status is inpatient or discharged. Request authorization via our Medical Intake Unit at Clear Coverage Electronic Preauthorization System Our electronic preauthorization system Clear Coverage, is a Web-based, real-time software developed by McKesson. Clear Coverage is available for you to use when requesting referrals and preauthorizations and it is accessible via our website, ExcellusBCBS.com/ProviderReferralsAuths. We are excited to offer you greater selfservice options and immediate resolution of preauthorization requests through this online tool. Clear Coverage offers: Faster turnaround: 60 percent to 80 percent of requests are answered immediately Faster pending case resolution: most clinical information is immediately accessed for clinical evaluation Evidence-based clinical decision support: includes InterQual criteria for standards of care, as well as regional product specific medical policy criteria, when applicable Single point-of-access: consolidated workflow for many types of authorizations across multiple payers; allows administration of various payment rules for coordination of benefits Use Clear Coverage to request preauthorization for items listed on our preauthorization list, including: Specialty referrals Outpatient services Procedures (e.g., elective surgery) performed inpatient or outpatient. Please reference our Clinical Review preauthorization list (available on our website). If you are a new user to Clear Coverage and you have not yet received your facets ID number, you can click on the Get your Facets Provider ID link via the Referrals & Auths section of our website. You will be given an option to either call for your ID number, or you can send an and you will receive the ID number in two days. For instructions on how to use Clear Coverage and to access tip sheets, visit the Education section of our website at ExcellusBCBS.com/ProviderEducation. In addition, you may contact your Provider Relations representative to schedule training. Please direct questions related to Clear Coverage to our Customer Care Medical Intake number at Access referral and authorization information at ExcellusBCBS.com/ProviderReferralsAuths 37

39 Updates to Referral and Authorization Guidelines Our referral and authorization guidelines are updated annually (unless a change is required - if that is the case, we will notify you via a bulletin, or an article in our Connection newsletter). 38

40 Course 4 Review 4.4 Answer the questions below based on what you learned in Course Who is responsible for requesting a referral? 2. How do you request a referral? 3. What is a preauthorization? 4. Who should obtain a preauthorization? 5. How do you request a preauthorization? 6. What is the difference between referrals and preauthorizations? 7. What vendor do we use for radiology, sleep management and implantable cardiac devices preauthorizations 8. What is our Clear Coverage authorization tool? 39

41 Course 5 Pharmacy Benefit Management Medical Drug Benefit Medical Specialty Medication Prior Authorization Requirements Prescription Drug Benefit Course 5 Review

42 Medical Drug Benefit 5.1 Medical Drugs Medical drugs are defined as those drugs that are administered by a health care provider in the office, at an infusion center, at an outpatient facility or by nurses in home care. Medical drugs are covered under a member s medical benefit. (Prescription drugs are defined as those drugs that can be self-administered and are covered under a member s prescription drug benefit.) Some medical drugs may also fall into the category of Medical Specialty Drugs due to limited distribution or other unique characteristics. These may require preauthorization. Please refer to our website for additional information, including a list of provider-administered drugs that require preauthorization, information about contracted specialty pharmacies and specific medical drug policies. Go to ExcellusBCBS.com/ProviderPrescriptions > Prior Authorization & Step Therapy > Provider Administered Drugs Requiring Preauthorization. 41

43 Medical Specialty Medication Prior Authorization Requirements 5.2 Medical Specialty Medication Review Program Prior authorization is handled through our Clear Coverage Web tool. For additional information on Clear Coverage, access the Resource Guide and Tip Sheets via the Education section of our website. Your Provider Relations Representative is also available to provide in-office training on this Web tool. Specialty Medications Select number of drugs that require prior authorization and clinical review Drugs are available through specialty pharmacies Request for prior authorization can be done through Clear Coverage Once approved, the specialty pharmacy will ship the medication directly to the provider Medical drugs may be added to the prior authorization list as they are reviewed. Check our website frequently for updates to the list. Go to: ExcellusBCBS.com/ProviderPrescriptions > Prior Authorization & Step Therapy > Provider Administered Drugs Requiring Preauthorization Specialty Pharmacy is an Option for Obtaining Medical Drugs Excellus BCBS offers providers the option of using specialty pharmacies to obtain drugs that providers prefer not to stock in the office. Excellus BCBS s contracted specialty pharmacies will ship the drug to the provider s office and bill Excellus BCBS directly. What you need to know. Most medical drugs and medical specialty drugs may be obtained either through a contracted specialty pharmacy or purchased directly by a physician and billed to Excellus BCBS. Please note that you do not bill Excellus BCBS for the drug when using a specialty pharmacy. Specialty Pharmacies: What s the process? The drug you wish to prescribe requires preauthorization. 1. Use Clear Coverage Web tool to obtain preauthorization. 2. Once approved, the specialty pharmacy will ship the medication directly to the provider. The drug you wish to prescribe does NOT require preauthorization. 1. Complete the appropriate prescription form. 2. In addition to the prescription, include member-specific insurance and demographic information. 3. Fax the prescription with the additional information above to the specialty pharmacy. (See specialty pharmacy fax numbers on the Contact Us grid) 42

44 Prescription Drug Benefit 5.3 Prescription Drugs Prescription drugs are drugs that can be self-administered. Medication Guides Excellus BCBS makes a three-tier formulary guide as well as a closed formulary guide available to employers. Both list generic and brand-name medications. The Pharmacy and Therapeutics Committee, composed of practicing community physicians and clinical pharmacists, defines the drugs in each category. The committee meets regularly to review the drugs on the formularies. Both the three-tier and the closed formulary can be accessed via the Excellus BCBS website, ExcellusBCBS.com/ProviderPrescriptions > Check Out Our Drug List. Three Tier Drug Plan This drug benefit design provides three tiers of coverage with a graduating scale of patient copayment/coinsurance based on the tier assignment of the prescribed drug. Our members play a vital role in controlling the rising cost of prescription drugs, and this three-tier benefit gives them the incentive to make informed decisions about the medications they take. Tier One: Tier Two: Tier Three: Generally, generic drugs. Generic drugs have the same active ingredients, strength and effectiveness as their brand-name counterparts, but at a substantially lower cost. Generally, brand-name products selected because of their overall value. All other prescription drugs including FDA-approved drugs that are pending. The three-tier prescription benefit focuses on cost-sharing. Members using Tier Three drugs will be responsible for the highest out-of-pocket expenses. 43

45 Medicare Part D Drug Coverage Medicare Part D drug coverage is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of Monthly premium paid to private payers Private plans that meet federal requirements can offer a Medicare Part D drug program For plans that offer Medicare Advantage programs (such as Medicare Blue PPO), the prescription drug program is automatically offered Regional Prescription Drug Plans (PDP s) are assigned by Medicare to offer the prescription drug program directly to subscribers Specific formularies apply for Medicare Part D coverage Medicare Part D medication guides (formularies) are located on our website Closed Formulary The closed formulary prescription drug benefit is designed to provide value. Under a closed formulary, only specific drugs in each therapeutic class are covered. Formulary Generic Drugs: These drugs meet Excellus BCBS requirements for a Formulary Generic drug. Generic drugs have the same active ingredients, strength and effectiveness as their brand-name counterparts, but at a substantially lower cost (not all generic drugs will be Formulary Generic drugs). Formulary Brand Drugs: These are drugs that have been selected as Formulary Brand Drugs because of their overall value. The closed formulary design ensures that members and practitioners have adequate options in each therapeutic category. Formulary drugs include most generic and selected brands. Medications classified as nonformulary are generally not covered under the benefit. Non-formulary medications must meet medical necessity criteria through an exception process in order to be covered under the member's prescription benefit. Online Drug Claims Processing Our online drug claims processing system provides safety and accuracy checks. As a prescription is filled, the system checks it against a series of safety and quality criteria, including: Quantity Limits: Limits apply based on standard FDA-approved dosing and established, clinically appropriate dosing parameters. Drug Utilization Review Messaging: Messages assure member safety by providing information about possible drug interactions, duplications and dosing errors. 44

46 Prescription Drugs Requiring Prior Authorization Step Therapy Program The Step Therapy program promotes the use of clinically sound generics and cost-effective therapeutic alternatives in select therapeutic classes. The program provides recommendations for prescribing first-line medications. The program applies to members with prescription drug benefits that include prior authorization requirements. As part of the program, we require prior authorization for certain drugs within select categories. The Step Therapy Program applies to new starts for members who have not had a trial of the recommended generic or lower-cost drug within the last year. For example, a patient who is prescribed Cozaar for the first time and has had a trial of Avapro will NOT require prior authorization. Prior Authorization We offer a drug-specific prior authorization form for each drug or drug category. For those drugs requiring prior authorization, prescribing practitioners must complete and submit the appropriate prior authorization form. (Drugs that require prior authorization are also indicated on the formulary.) The most current version of each form is available from the website, ExcellusBCBS.com/ProviderPrescriptions > Prior Authorization & Step Therapy > Access Prior Authorization Request Forms. Practitioners may also call our Pharmacy Help Desk to request the appropriate form. We will fax or mail the form directly to the requestor. Prescribing practitioners must complete all required fields on the prior authorization forms, including the member s ID number, located on the front of the member ID card. We will return incomplete forms for correction before a review determination can be made. Practitioners must fax prior authorizations or step therapy exceptions to our Pharmacy Help Desk. (The fax number is included on each form.) An automatic server will fax back the responses to the practitioner s office. Offices without access to a fax machine may call or write to our Pharmacy Help Desk to request prior authorization approval. To expedite the process, providers should have all required information available prior to placing the call. Exception Process To request an exception to the formulary, prior authorization, step therapy and other use management programs, the prescribing physician must complete a Request for Drug Evaluation form and fax it to our Pharmacy Help Desk at the number listed at the bottom of the form. The Request for Drug Evaluation form is available on ExcellusBCBS.com/ProviderPrescriptions. 45

47 Generic Advantage Program: Our prescription drug benefit is designed to encourage value when selecting prescription drugs. The Generic Advantage Program for maximum allowable cost is part of our drug benefit. This program applies to a list of brand name drugs that have Food and Drug Administration (FDA) approved generic alternatives. How it works: If members purchase a brand name medication when there is a generic equivalent available, they will pay: the generic copayment/coinsurance amount, and the difference between the cost of the more costly brand name medication and our price for the less expensive generic. Learn more at ExcellusBCBS.com/ProviderPrescriptions. Mail Order Pharmacy: For a saving of up to 33 percent on prescriptions, encourage your patients to fill their prescriptions with one of our home delivery pharmacies. Your patients can enjoy the convenience of filling their prescriptions by phone or online and having them delivered to their home. Medications can be ordered online, over the phone or through the mail. Your patients can get up to a 90-day supply of medication at one time. For a list of participating prescription home delivery pharmacies, visit: ExcellusBCBS.com/wps/portal/xl//mbr/drg/mailpharmacy. Take Medication As Directed: One of the most important things your patients can do to protect their health is to take their medications as directed. This is called medication adherence. Not taking medication as directed includes: Not filling a new prescription, Not picking up your medicine at the pharmacy, Not refilling an existing prescription when you should, Not taking medicine as you should (including skipping or stopping doses), Taking more or less of a prescribed medicine, and Taking medicine at the wrong time. For valuable information to share with your patients on medication adherence, and to learn more about our TAD campaign, visit: ExcellusBCBS.com/wps/portal/xl/mbr/drg/mngmeds/take-as-directed 46

48 Course 5 Review 5.4 Answer the questions below based on what you learned in Course When drugs are administered by a health care professional in the office, infusion center, outpatient facility or via home infusion, which pharmacy benefit do they fall under? 2. Our Medical Specialty Medication Review program unit is staffed by whom? 3. Where can you obtain medical drug prior authorizations and forms? 4. Do you bill Excellus BCBS when using a specialty pharmacy? 5. When drugs can be self-administered, which pharmacy benefit do they fall under? 6. Name two ways that the Medicare Part D program is administered. 7. How many tiers are located on the Excellus BCBS commercial formulary? 8. What is Step Therapy? 9. Do we offer a generic advantage program? 10. What does TAD stand for? 47

49 Course 6 Working with Us Communications Access and Availability Credentialing and Recredentialing Website Forms 6.5 Course 6 Review

50 Communications 6.1 How We Communicate With Your Office Connection Newsletter The Connection newsletter is published and posted to our website, ExcellusBCBS.com/Provider, on a monthly basis. Following its posting, an ealert that links to the newsletter is ed to providers who opt-in to receive the publication electronically. The newsletter notification is only sent to those who have completed the opt-in process. The Connection newsletter is your office s best source for obtaining information regarding: Billing and claims Mandates Reimbursement policies Medical policies New products Tools for your practice Important news And much more Opt-in Today! Opting in is easy and it only takes a few moments! Go to ExcellusBCBS.com/ProviderNewsUpdates > Follow this link to receive our monthly newsletter and provider communications by . Enter the requested information and click submit. Your information will automatically be loaded to our distribution list, and you will receive a confirmation . Provider Bulletins and Letters Bulletins and letters are used for information requiring immediate attention or to introduce important new products and programs. These communications explain specific updates and/or changes. Provider Manual The manual is a reference and source document. It clarifies and supplements various provisions of a provider s participation agreement. The manual contains relevant program policies and procedures with accompanying explanations and exhibits. It s important that staff who performs administrative, billing and quality assurance functions have a copy of the manual. The manual is updated annually and is available via the website, ExcellusBCBS.com/wps/portal/xl/prv/edu/providermanual/. You must log-in to our website with your username and password to access the manual. 49

51 Navigating the Blues Educational Series The Navigating the Blues seminars is hosted by our Provider Relations staff and presents a series of classes offered in all regions. Schedule and registration is available from the Staff Training section of our website, ExcellusBCBS.com/ProviderStaffTraining, and advertised in the Connection newsletter. Provider Seminars Provider Relations hosts annual seminars to keep you current regarding changes and products. Information about upcoming events can be found in the Connection newsletter and is posted to the Staff Training section of our website, ExcellusBCBS.com/ProviderStaffTraining. Provider Satisfaction and Office Manager Surveys We send provider satisfaction and office manager surveys out on a yearly basis in order to get your feedback. Please take a few moments to complete them. We read them and, where possible, make changes based on your comments. Website Excellus BCBS s website is an indispensable source of information benefiting your practice and your patients. Visit Excellusbcbs.com/Provider to: Check member eligibility and benefits Obtain claim information Access Clear Coverage preauthorization tool Review medical and administrative policies View pharmacy information Print various forms Access our Connection newsletter Read provider bulletins Update your practice information Customer Care Customer Care advocates are available to assist you: Monday - Thursday: 8 a.m. 5:30 p.m. and Friday: 9 a.m. - 5:30 p.m. Call Customer Care with questions regarding: Appeals Medical and administrative policies Claim denial Benefits Member eligibility Claim pricing Referral status Coordination of benefits Provider Relations Your Provider Relations representative is an important resource for communicating with Excellus BCBS and is available to meet with you personally regarding: Office training sessions New products and updates Community programs and provider partnership Regulatory mandates affecting daily operations (e.g., HIPAA, NPI, etc.) Website training, including our Clear Coverage preauthorization tool Billing policies and procedures 50

52 Access and Availability 6.2 We follow availability standards, outlined below, established by the New York State Department of Health. These standards, which apply to all lines of business, are used to improve patient access to routine, urgent, preventive, specialty and behavioral health care. We also follow 24-hour access standards to measure after-hours access. Additional information on access and availability is posted on our website at ExcellusBCBS.com/ProviderPatientCare > Quality Improvement > click on the Standards tab. Access and Availability tip sheets can be found at ExcellusBCBS.com/ProviderStaffTraining. Care Needed Urgent Care Non-Urgent Sick Well Child/Preventive Routine Preventive (non-urgent) Specialist Referral (non-urgent) Adult Baseline/Routine Physical Newborn Initial Visit Initial Prenatal Visits Behavioral Health Care Urgent visit Routine visit After-hours life-threatening behavioral health emergency After-hours non-life-threatening behavioral health emergency 51 Time Frame Within 24 Hours Within Hours Within 4 Weeks Within 4 Weeks Within 4-6 Weeks Within 12 Weeks Within 2 Weeks of Hospital Discharge First Trimester: Within 3 Weeks Second Trimester: Within 2 Weeks Third Trimester: Within 1 Week Within 48 hours or less Within 10 days or less Assessable immediately by telephone, within 24 hours, 7 days a week Within 6 hours or less Accepting new patients? Did you know? Medical Records - While your office may require a new patient s medical records, the records cannot serve as a prerequisite to scheduling an appointment. Health Questionnaires Having a patient complete a health questionnaire helps you get to know the patient; however, you cannot require a completed questionnaire prior to scheduling an appointment. Did you know? Failure to comply with accessibility guidelines constitutes a breach of your participating provider agreement, and may be cause for termination from the provider panel. Additionally, the New York Education Department Office of Professions and Code of Ethics for each discipline (i.e., psychiatrist, psychologist and licensed clinical social worker-r) support the after-hours accessibility guidelines for active members with a lifethreatening emergency.

53 Appointment Wait Times (primary care site): Should not exceed one hour for scheduled appointments. 24-Hour Phone Coverage: To help ensure continuous 24-hour coverage, primary care providers must maintain one of the following arrangements for members to contact after normal business hours: Office phone answered by an answering service that can contact the primary care provider or another designated network medical practitioner. Office phone message should direct the member to call another number to reach the primary care provider or anotherprovider designated by the primary care provider. Someone must be available to answer the designated provider s phone; another recording is not acceptable. Office phone transferred to another location where someone will answer the phone. The person answering calls must be able to contact the primary care provider or a designated network medical practitioner. Please be aware that the following phone answering procedures are not acceptable: Answer the phone only during office hours. Answer the phone after-hours by a recording that tells members to leave a message. Answer the phone after-hours by a recording that directs the members to go to an ER for any services. Life-Threatening Behavioral Health Care After-hours Telephone Answering Options: Behavioral Health providers are required to provide necessary telephonic services to members 24 hours a day, 7 days a week in case of telephone calls from established patients or patients family members concerning clinical mental health emergencies. This is critical for coordinating care when your patient has presented to the emergency room with an urgent/emergent or life-threatening crisis. Providers must also arrange for complete backup coverage with other participating clinician(s) that can provide the same level of care in the event the practitioner is unable to provide covered services to established patients. Members must be able to: Reach the practitioner or a person with the ability to patch the call through to the practitioner (e.g., answering service, pager); or Reach an answering machine or voic with instructions on how to contact the practitioner or his/her backup (e.g., message with number for home, cell phone or beeper) in case of a clinical urgent/emergent situation. Call forwarding may also be used, but the message must state that the call is being forwarded to the practitioner s contact number. The practitioner s answering machine messages is automatically forwarded to a phone (e.g., practitioner s cell phone, pager) where the practitioner retrieves and responds to those messages for life-threatening emergencies, after-hours, as soon as possible. Unacceptable answering options: Reaching an answering machine that instructs the active member to go to the nearest emergency room, crisis center hotline, lifeline and/or call 911. Reaching an answering machine with no instructions. Reaching an answering machine recommending the member call during business hours. No answer. A busy signal three times, within 30 minutes. 52

54 Credentialing and Recredentialing 6.3 We welcome health care providers to participate in our network. We contract with physicians, facilities and other health care professionals to form provider networks essential for the delivery of quality, accessible and affordable health care services to our members. To help ensure that our members receive quality care, we recredential participating providers at least every three years. To learn more, visit: ExcellusBCBS.com/ProviderContactUs > Join Our Network Electronic Credentialing and Recredentialing We are pleased to participate in the Universal Provider DataSource, a project of the Council for Affordable Quality Healthcare (CAQH). This web-based solution allows you to store and manage your credentialing information online and share it with insurance carriers electronically. By using this single source, you no longer need to complete different credentialing applications for different insurance carriers. Simply enter your information once and authorize insurance carriers (including Excellus BCBS) to access it. How it works: To access the Universal Provider DataSource, visit: Under Providers, click: 'Go to the Universal Provider Datasource' and log in Enter your CAQH Provider ID (if you don't know your ID, call CAQH at ) Enter or update your information Authorize Excellus BCBS to access your information electronically For more information or to view an online demonstration of this tool, visit: 53

55 Website 6.4 Convenient Self-Service Visit the Excellus BCBS website, ExcellusBCBS.com/Provider, to see why more providers choose to CLICK with us! From news and information to forms and formularies our website offers the resources and information you need, right at your fingertips! Save Time, Go Online Check claim status & request adjustments Check, enter, update and delete referrals Check member eligibility & benefits Enter an emergency admission View clinical review requirements Update practice information Review referral guidelines Request preauthorizations Read medical and administrative policies Review Provider Manuals Connect patients with health resources Access to prescription drug information medication guide, prior authorization forms, specialty pharmacy network Download forms And much MORE! You must be a registered website user to have complete access to online tools and resources. Registering only takes a few moments. Visit ExcellusBCBS.com/Provider Scroll to Register Now! Select the role that applies from the I am a drop-down menu, then click GO. Enter your information, and then click Submit Log in with your username and password Need Assistance Registering? Contact the Web Security Help Desk at Your Provider Relations Representative is also available for training on Web registration and functionality. 54

56 Get your patients to CLICK with US! We offer exceptional Web tools to help your patients manage their: health, health costs, Excellus BCBS account and much MORE! Registered Providers log in with your username and password! If you haven t registered, do it today! Select your position from the dropdown menu and complete the registration form. If you have questions, call our Web Security Help Desk at Registering ensures that you have complete access to our online tools and resources. Don t delay, register today! 55

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58 Forms

59 Course 6 Review 6.6 Answer the questions below based on what you learned in Course What is the name of the Web-based system for submitting credentialing information? 2. How often are providers recredentialed? 3. What is the name of our monthly newsletter? 4. Besides the newsletter, how else do we communicate with your office? 5. Do you have to opt-in to receive communications via ealert? 6. Can you find access and availability standards information on our website? If yes, where is it located? 7. When is Customer Care open? Time and days of the week. 8. Who should you contact for training in your office? 9. What is the website address to the Provider section of the Excellus BCBS website? 10. What are some reasons to click before you call Customer Care? 58

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