What are the roles and responsibilities of BlueCross BlueShield of Tennessee to the providers?

Transcription

1 BlueCard Prgram Answers t Frequently Asked Questins What is the BlueCard Prgram? BlueCard is a natinal prgram that enables members f ne Blue Plan t btain healthcare service benefits while traveling r living in anther Blue Plan s service area. The prgram links participating healthcare prviders with the independent Blue Crss and Blue Shield Plans acrss the cuntry, and in mre than 200 cuntries and territries wrldwide, thrugh a single electrnic netwrk fr claims prcessing and reimbursement. Yu may submit claims fr patients frm ther Blue Plans, dmestic and internatinal, t yur lcal Blue Crss and/r Blue Shield Plan. The lcal Blue Crss and/r Blue Shield Plan is yur sle cntact fr educatin, cntracting, claims payment/adjustments and prblem reslutin. Questins by Tpic (click n the tpic) Rles and Respnsibilities Eligibility and Benefits Claims Submissin Crdinatin f Benefits (COB) Prir Authrizatin and/r Pre-Certificatin Medical Recrds Medical, Benefit, Payment Plicy Claims Payment Medicare Crssver Medicare Advantage Ancillary Claims Filing Cntiguus Cunties/Overlapping Service Areas Additinal Infrmatin Rles and Respnsibilities What are the rles and respnsibilities f BlueCrss BlueShield f Tennessee t the prviders? BlueCrss BlueShield f Tennessee s respnsibilities includes all prvider related functins, such as: Being the single cntact fr all claims payment, custmer service issues, prvider educatin, adjustments and appeals Pricing claims and applying pricing and reimbursement rules cnsistent with prvider cntractual agreements. Frwarding all clean claims received t the member s Blue Crss and Blue Shield Plan t adjudicate based n eligibility and cntractual benefits. 1

2 Cnducting apprpriate prvider reviews and/r audits. Cnfirming that prviders are perfrming services and filing claims apprpriately within their scpe f practice and accrding t their lcal Blue Crss and/r Blue Shield Plan. Cnducting HIPAA standard transactins Training fr prviders n BlueCard What are the rles and respnsibilities f the Member hme plan t the prvider? Adjudicate claims based n member eligibility and cntractual benefits. Respnd t prir authrizatin and pre-certificatin requests/inquiries. Request medical recrds thrugh the lcal Plan when review fr medical necessity, determinatin f a pre-existing cnditin, r high cst/utilizatin is required. What are the rles and respnsibilities fr the Prvider? Obtaining benefits and eligibility infrmatin, including cvered services, cpayments and deductible requirements. Filing claims with the crrect lcal Plan and including, at minimum, the required elements t ensure timely and crrect prcessing, such as: Current member ID card number All Other Party Liability infrmatin All member payments such c-pay, c-insurance r deductibles Submitting medical recrds in a timely manner when requested by the lcal r member hme Plan Eligibility and Benefits Hw can Prviders btain member eligibility infrmatin? Member eligibility infrmatin shuld be btained by submitting a Blue Exchange Eligibility & Benefits Inquiry (HIPAA transactin 270) request thrugh yur lcal Blue Plan, but can als be btained by calling BLUE(2583). If prir authrizatin r pre-certificatin infrmatin is required in additin t eligibility, Prviders shuld call BLUE(2583). It is mre beneficial when submitting a HIPAA transactin 270 request t use the apprpriate Service Type cdes fr the specific service being prvided. Use f the general Service Type 30 (Health Benefit Plan Cverage) r Service Type 1 (Medical Care) may nt prvide enugh infrmatin t address all related Inpatient, Outpatient, Emergency and Prfessinal benefits and des nt include infrmatin n Benefit Limitatins and Place f Service requirements. Verify the member s cst sharing amunt befre prcessing payment. C-pay, c-insurance, deductibles and accumulated benefits can be btained frm the electrnic Blue Exchange Eligibility & Benefits Respnse (HIPAA transactin 271) t the HIPAA transactin 270. Please d nt prcess full payment upfrnt. 2

3 What specific infrmatin shuld the Prvider Obtain? It is recmmended that Prviders request the mst current ID card at every visit since new ID cards maybe be issued t members thrughut the year. Member ID cards may include ne f several lgs identifying the type f cverage the member has and/r indicating the prvider s reimbursement level. Blank (empty) suitcase Traditinal, HMO (Health Maintenance Organizatin), POS (Pint f Service) and Limited Benefit Prduct type benefits PPO in suitcase PPO r EPO type benefits N suitcase Medicaid, State Children s Health Insurance Prgrams (SCHIP) administered as a part f a state s Medicaid prgram, Medicare Cmplementary and Supplemental prducts, als knwn as Medigap type benefits. The prvider shuld request specific infrmatin including eligibility, benefits, cst sharing, prir authrizatin/pre-certificatin requirements, care/utilizatin management requirements, and cncurrent review requirements when cntacting the member hme Plan fr benefit and eligibility infrmatin. Claim Submissin Hw shuld prviders bill claims fr ut-f-area members? Prviders shuld bill claims fr ut-f-area members the same way they bill claims fr their lcal Blue Crss and/r Blue Shield Plan members. When submitting the claim: The member ID numbers shuld be reprted exactly as shwn n the ID card. D nt add, mit r alter any characters frm the member ID number. Indicate n the claim any payment yu cllected frm the patient. Only submit medical recrds if requested. What shuld yu d if yu haven t received a respnse t yur initial claim submissin? If yu have a questin regarding the status f an utstanding claim, yu can submit an electrnic Blue Exchange Claim Status Request (HIPAA transactin 276) r cntact BlueCrss BlueShield f Tennessee.. D nt send in a duplicate claim. Sending anther claim r having yur billing agency resubmit claims autmatically slws dwn the claims payment prcess and creates cnfusin fr the member. Crdinatin f Benefits Hw shuld Crdinatin f Benefits (COB) be handled when a member has Blue n Blue cverage? Anther carrier? 3

4 In cases where Blue n Blue cverage has been identified, and the member has dual cverage with the same and/r differing Blue Plans yu shuld cnsider the fllwing: When submitting the claim, it is essential that yu enter the crrect Blue Plan name as the secndary carrier. This may be different frm the lcal Blue Plan. Check the member s ID card fr additinal verificatin r ask them t cmplete the Universal Blue COB Questinnaire available at On the electrnic HIPAA transactin 837 r paper claim, it is imprtant in bx 11D YES r NO be checked fr Prfessinal claims r frm fields 50, be cmpleted fr Institutinal claims t ensure the claim will be reviewed prperly by the lcal Blue Plan. Fr Prfessinal claims if the member des nt have ther insurance, it is imperative that yu indicate this. Leaving the bx unmarked can cause the Member s Hme Plan t stp the claim t investigate fr COB. By cmpleting the infrmatin, yu are helping ensure yur claim will be prcessed mre timely. Review the EOP/EOB frm the primary Blue Plan prir t submitting a claim t the secndary Blue Plan t avid duplicate claims submissin. The primary Blue Plan may have frwarded the claim t the secndary Blue Plan thrugh BlueCard. If BlueCrss BlueShield f Tennessee did nt handle the secndary claim, then frward a cpy f the claim t yur lcal Blue Plan with any Other Party Liability (OPL) infrmatin included. Carefully review the payment infrmatin frm all payers invlved n the remittance advice befre balance billing the patient fr any ptential liability. In cases where there is mre than ne payer and anther Blue Plan r cmmercial insurance carrier is the primary payer, submit the ther carrier s name and address r Explanatin f Benefits with the claim t BlueCrss BlueShield f Tennessee. Yu may als g t dwnlad a cpy f the Universal Blue COB Questinnaire that the member can cmplete and sign at the time f service and send it t BlueCrss BlueShield f Tennessee with the claim. Please ensure that the frm is cmpletely filled ut and at a minimum, include yur name and tax identificatin r NPI number, the plicyhlder s name, grup number and identificatin number including the three-character alphaprefix and the member s signature. Nt including the COB infrmatin with the claim may delay payment if the members hme Plan investigates the claim needlessly. If anther nn-blue health plan is primary and any ther Blue Plan is secndary, submit the claim t the lcal Plan nly after receiving payment frm the primary payer. Include the explanatin f payment frm the primary carrier with yur claim submittal. Prir Authrizatin/Pre-Certificatin Are prviders required t cperate with the member s Blue Plan prir authrizatin/ pre-certificatin prgrams? While ut-f-area BlueCard members are currently respnsible fr btaining prir authrizatin r precertificatin frm their BCBS Plans, mst prviders chse t handle this bligatin n the member s behalf. Members may be held financially respnsible if necessary apprvals are nt btained and the claim is denied. The prvider may have t manage debt cllectin in this situatin. When verifying member eligibility and benefits, prviders shuld request infrmatin n prir authrizatin and pre-certificatin, care management/utilizatin management and cncurrent review, as required fr inpatient r utpatient services. Hw can Prviders btain prir authrizatin/pre-certificatin infrmatin fr ut-f-area members? 4

5 Member prir authrizatin r pre-certificatin infrmatin can be btained bth electrnically and telephnically. General infrmatin n prir authrizatin and pre-certificatin infrmatin can be fund at under Medical Plicy & Pre-Cert Infrmatin Ruter utilizing the three-letter prefix fund n the member ID card. Prviders can als cntact BLUE(2583) t btain prir authrizatin r pre-certificatin infrmatin. When prir authrizatin r pre-certificatin fr a specific member is handled separately frm eligibility verificatins at the member s Blue Plan, yur call will be ruted directly t the area that handles prir authrizatin r pre-certificatin. Yu will chse frm fur ptins depending n the type f service fr which yu are calling: Medical/Surgical Behaviral Health Diagnstic Imaging/Radilgy Durable/Hme Medical Equipment (D/HME) If yu are inquiring abut bth, eligibility and prir authrizatin r pre-certificatin, thrugh BLUE(2583), yur eligibility inquiry will be addressed first. Then yu will be transferred, as apprpriate, t the prir authrizatin r pre-certificatin area. Please nte that if a prir authrizatin and pre-certificatin determinatin is nt prvided at the time f the call, the determinatin may be cmmunicated t a different area (i.e. facility s Utilizatin Management area) than the area that initiated the pre-certificatin request. Prviders are encuraged t ask the member s Blue Plan abut this situatin when they call in rder t prevent duplicate requests. With the submissin f an Eligibility HIPAA transactin 270 request thrugh yur lcal Blue Plan, the Eligibility HIPAA transactin 271 respnse may indicate that a prir authrizatin r precertificatin is required fr an eligible service. Are facilities that are paid primarily n a DRG/case basis required t btain apprvals fr lengthf-stay beynd the riginal apprval? Whenever pssible member Hme Plans will cnsider the lcal Plan's payment arrangement with the facility, and if apprpriate, adjust UM prtcls accrdingly. Many DRG cntracts have stp lss prvisins and revert t an alternative payment methd, i.e., percent f charges, at a particular pint during the curse f stay. These cases need t be managed apprpriately. Member Hme Plans may wrk clsely with the facility and/r lcal Plan t manage these ptentially high-cst cases. Claims culd be subjected t length-f-stay review and ptential sanctins. Prviders cannt assume that if they are cntacted as a DRG facility, n cncurrent review will ccur. The member hme plan cannt split payment fr claims with BlueCrss BlueShield f Tennessee DRG pricing. The member s hme plan must either apprve r deny the entire claim. They may nt pay nly fr specific days and deny thers. If the treatment plan changes during the inpatient stay, the riginal apprval wuld nt be applicable and new certificatin wuld need t be btained. The prvider can call BLUE(2583) and request t speak with the Utilizatin Review area r submit a Blue Exchange Referral/Authrizatin Inquiry (HIPAA transactin 278) t the lcal Plan. Prviders are encuraged t inquire abut cncurrent review prcess when verifying member eligibility and benefits r when btaining pre-certificatin s they are aware f what steps are 5

6 needed t satisfy the member s Hme Plan cncurrent review requirements. Prvider benefits f the cncurrent review prcess are: Assist with crdinated discharge planning Identify care management pprtunities fr the member Help t reduce patient readmissin Why d member s Blue Plans smetimes initially indicate that a service/prcedure is authrized r certified under an authrizatin r certificatin prcess, but when the service is adjudicated, determine the service t be nn-cvered/denied? These discrepancies tend t ccur when there is benefit limitatins that restrict wh may render the service, where they are rendered, hw they are billed, r the presence f a benefit maximum. Additinal factrs that may affect adjudicatin f a claim are pre-existing cnditins, additinal services nt included in the initial plan f treatment and/r a revised length f stay that des nt match the prir authrizatin r pre-certificatin. When btaining prir authrizatin r pre-certificatin, please prvide as much infrmatin as pssible, t minimize ptential claims issues. Prviders are encuraged t fllw-up immediately with a member s Blue Plan t cmmunicate any changes in treatment r setting t ensure existing authrizatin is mdified r a new ne is btained, if needed. Failure t make the necessary ntificatin r btain prir authrizatin/pre-certificatin may cause a delay r denial in claims payment. Please nte that prir authrizatin r pre-certificatin des nt guarantee payment. Are prviders required t hld the patient harmless fr penalties assessed fr nt fllwing the member s Blue Plan authrizatin prtcls? The ut-f-area BlueCard member is respnsible fr btaining pre-certificatin r prir authrizatin frm his/her Blue Crss and/r Blue Shield Plan. As a result, the member is respnsible fr any penalty assessed fr nn-cmpliance. Medical Recrds Shuld a prvider include medical recrds with the riginal claim? Prviders are nt encuraged t submit unslicited medical recrds r ther clinical infrmatin unless requested. If medical recrds r ther relevant infrmatin is needed t finalize the claim payment, BlueCrss BlueShield f Tennessee will ntify yu. If yu receive requests fr medical recrds frm ther Blue Plans prir t rendering services, as part f the prir authrizatin prcess, please submit them directly t the member s Plan that requested them. Fllw the submissin instructins given n the request, using the specified physical r address r fax number. The address r fax number fr medical recrds may be different frm the address yu use t submit claims. There is a difference between reviewing a claim fr medical necessity after the service has already been rendered and reviewing a prir authrizatin fr medical apprpriateness; these reviews are nt the same: Medical Necessity - validates the service is medically necessary accrding t their members Blue Plan medical plicy. Medically Apprpriate - validates that service rendered matches the prir authrizatin and the dllar amunts are in-line. 6

7 When a claim has been denied fr medical recrds and the recrds have been submitted t BlueCrss BlueShield f Tennessee, it is recmmended that prviders wait at a minimum 20 business days befre submitting a fllw up request fr status f claim adjudicatin. If yu are the rendering r perfrming prvider fr a service, include the name and address f the referring r rdering prvider n yur riginal claim submissin. Including this infrmatin will help ensure that if medical recrds are needed that they will be requested frm the crrect prvider. Medical, Benefit, Payment Plicy Which Plan s Medical Plicy applies fr ut-f-area members? Only a member s Blue Plan Medical Plicy applies t BlueCard claims. The member s Blue Plan Medical Plicy applies t the interpretatin and determinatin f medical necessity, medical apprpriateness, investigatinal/experimental care, and clinical reviews as related t administratin f the member s benefits and cverage. Shuld a member s Blue Plan ever directly cntact an ut-f-area prvider? The member s Blue Plan shuld nly cntact an ut-f-area prvider t slicit, clarify, r cnfirm clinical infrmatin fr perfrming case management r disease management activities. Hw shuld prviders bill mther/newbrn claims fr ut-f-area members? Prviders shuld bill mther/newbrn services fr ut-f-area members the same way they bill claims fr lcal Blue Crss and/r Blue Shield members. Wh determines the use f revenue/prcedure cdes? It is the lcal Plans respnsibility fr claims cding based n the cntractual agreement with the prvider. When a claim cntains nn-standard cdes, it maybe be rejected back t the prvider, and the prvider may be asked t resubmit with the standard cde. Wh determines the apprpriate use f mdifiers? The lcal Blue Crss and/r Blue Shield Plan is respnsible fr determining the apprpriate use f mdifiers.. Hw much can a cntracted prvider bill an ut-f-area Blue member? Prviders shuld nly bill fr applicable deductibles, c-pays, c-insurance, nn-cvered services and/r medical management penalties specifically indicated as Patient Respnsibility n the remittance advice fr such ut-f-area Blue Plan member. The prvider cannt in any event, bill the ut-f-area member fr the difference between billed charges and the lcally negtiated allwance. What criteria are used t determine whether the charge assciated with a rendered service is a member r a cntracting prvider s liability? The criteria used t determine the prvider s liability is specific t the prvider s cntract. If the prvider s cntract explicitly states the prvider will nt be reimbursed fr a specific service r based n a specific timeframe, and cannt bill the member, the prvider is liable fr the charge. The criteria used t determine the member s liability is specific t the member s benefit cntract. If the member s benefit explicitly states the service is nt cvered, the member is liable fr the charge. 7

8 Under what circumstances is there n payment due t the prvider? BlueCrss BlueShield f Tennessee prices claims accrding t the terms f its prvider cntracts. If a prvider s cntract has a clause stating prviders are liable fr any csts assciated with services rendered utside the prvider s scpe f practice, BlueCrss BlueShield f Tennessee will indicate n payment is due t the prvider. If the member s benefit allws the service, but the prvider s cntract des nt, benefits will be apprved, but n payment is due the prvider accrding t his/her cntract and the prvider shuld write it ff. Claims Payment Hw is a Prvider payment determined? The lcal Plan applies pricing and reimbursement rules cnsistent with prvider cntractual agreements. The member s hme Plan adjudicates the claim based n eligibility and cntractual benefits. Wh pays the Prvider? Prvider payable claims will be paid by the lcal Plan based n the prvider s cntract and subject t the member s benefit plan. Medicare Crssver All Blue Plans crssver Medicare claims fr services cvered under Medigap and Medicare Supplemental prducts. This will result in autmatic claims submissin f Medicare claims t the Blue secndary payer, and reduce r eliminate the need fr the prvider s ffice r billing service t submit an additinal claim t the secndary carrier. Hw d I submit Medicare primary / Blue Plan secndary claims? Fr members with Medicare primary cverage and Blue Plan secndary cverage, submit claims t yur Medicare intermediary and/r Medicare carrier. When submitting the claim, it is essential that yu enter the crrect Blue Plan name as the secndary carrier. This may be different frm the lcal Blue Plan. Check the member s ID card fr additinal verificatin. Be certain t include the alpha prefix as part f the member identificatin number. The member s ID card will include the alpha prefix in the first three psitins. The alpha prefix is critical fr cnfirming membership and cverage, and key t facilitating prmpt payments. When shuld I expect t receive payment fr Medicare Crssver claims? The claims yu submit t the Medicare intermediary will be crssed ver t the Blue Plan after they have been prcessed by the Medicare intermediary. This prcess may take up t 14 business days. This means that the Medicare intermediary will be releasing the claim t the Blue Plan fr prcessing abut the same time yu receive the Medicare remittance advice. As a result, it may take an additinal business days fr yu t receive payment frm the Blue Plan. T determine if yur claim has crssed ver, review the Remittance Advice (RA) yu receive frm Medicare. The RA will shw a crssver indicatr that Medicare has submitted the claim t the 8

9 apprpriate Blue Plan and the claim is in prgress. If there is n crssver indicatr n the RA, prviders shuld submit the claim alng with the Medicare RA t the lcal Plan. Medicare Advantage Hw d I handle Medicare Advantage (MA) claims? Fr Medicare Advantage, submit claims t the lcal Blue Plan. D nt bill Medicare directly fr any services rendered t a Medicare Advantage member. Ask fr the member ID card. Members will nt have a standard Medicare card; instead, Medicare Advantage members have distinctive prduct lgs n their medical ID card t help yu recgnize them. All lgs have the term Medicare Advantage in the design. Verify eligibility by cntacting BLUE(2583) and prviding the alpha prefix. Be sure t ask if Medicare Advantage benefits apply. Please review the remittance ntice cncerning Medicare Advantage plan payment, member s payment respnsibility and balance billing limitatins. What des Medicare Advantage PPO Netwrk Sharing mean? If yu are a cntracted MA PPO prvider with the lcal plan and yu see MA PPO members frm ther Blue Plans, these members will be extended the same cntractual access t care and will be reimbursed in accrdance with yur negtiated rate with yur lcal Blue Plan cntract. These members will receive innetwrk benefits in accrdance with their member cntract. NOTE: If yu are nt a cntracted MA PPO prvider with yur lcal Plan and yu prvide services fr any Blue MA members, yu will receive the Medicare allwed amunt fr cvered services. Fr Urgent r Emergency care, yu will be reimbursed at the member s in-netwrk benefit level. Other services will be reimbursed at the ut-f-netwrk benefit level. Ancillary Claims Filing Where shuld I file Ancillary Claims? Ancillary prviders include Independent Clinical Labratry, Durable/Hme Medical Equipment and Supplies and Specialty Pharmacy prviders. File claims fr these prviders as fllws: Independent Clinical Labratry (Lab) The Plan in whse state* the specimen was drawn. Durable/Hme Medical Equipment and Supplies (D/HME) The Plan in whse state* the equipment was shipped t r purchased at a retail stre. Specialty Pharmacy The Plan in whse state* the Ordering Physician is lcated. *If yu cntract with mre than ne Plan in a state fr the same prduct type (i.e., PPO r Traditinal), yu may file the claim with either Plan. Cntiguus Cunties/Overlapping Service Areas What are the rules fr filing claims fr Cntiguus Cunties? 9

10 Claims filing rules fr cntiguus area prviders are based n the permitted terms f the prvider cntact, which may include: Prvider Lcatin (i.e. which Plan service area is the prviders ffice lcated) Prvider cntract with the tw cntiguus cunties (i.e. is the prvider cntracted with nly ne r bth service areas). The member s Hme plan and where the member wrks and resides (i.e. is the member s Hme Plan with ne f the cntiguus cunties plans). The lcatin f where the services were received (i.e. des the member wrk and reside in ne cntiguus cunty and see a prvider in anther cntiguus cunty). NOTE: Cntiguus Cunties guidelines d nt apply t Ancillary Claims Filing. Ancillary claims must be filed t the lcal Plan based n the type f ancillary service prvided. What are the rules fr filing claims in Overlapping Service Areas? Submissin f claims in Overlapping Service Areas is dependent n what Plan(s) the Prvider cntracts with in that state, the type f cntract the Prvider has (ex. PPO, Traditinal) and the type f cntract the member has with their Hme Plan. If yu cntract with all lcal Blue Plans in yur state fr the same prduct type (i.e., PPO r Traditinal), yu may file an ut-f-area Blue Plan member s claim with either Plan. If yu have a PPO cntract with ne Blue Plan, but a Traditinal cntract with anther Blue Plan, file the ut-f-area Blue Plan member s claim by prduct type. Fr example, if it s a PPO member, file the claim with the Plan that has yur PPO cntract. If yu cntract with ne Plan but nt the ther, file all ut-f-area claims with yur cntracted Plan. Additinal Infrmatin What is an Administrative Services Only (ASO) accunt? ASO accunts are self-funded, where the lcal plan administers claims n behalf f the accunt, but des nt fully underwrite the claims. ASO accunts may have benefit r claims prcessing requirements that may differ frm nn-aso accunts. There may be specific requirements that affect; medical benefits, submissin f medical recrds, Crdinatin f Benefits r timely filing limitatins. The lcal plan receives and prices all lcal claims, handles all interactins with prviders, with the exceptin f Utilizatin Management interactins, and makes payment t the lcal prvider. As with any member benefit cntract be sure t verify member eligibility and benefits when rendering service. Hw shuld clearinghuses be ntified f changes in claims prcessing guidelines r plicy? It is the Prviders respnsibility t ensure any changes t claims prcessing guidelines r plicy is cmmunicated t any billing service, clearinghuse r payer the prvider has a vendr arrangement with t prcess yur claims. Failure t d s in a timely manner may result in delays r denials f payment due t incrrect claims submissin. 10