2.0 Administrative Information

Transcription

1 Excellus BlueCross BlueShield Participating Provider Manual 2.0 Administrative Information 2.1 Contacting the Health Plan The Health Plan employs individuals trained to perform specific services and support specific provider needs. The following Contact List includes telephone numbers, fax numbers, addresses, Web page addresses and addresses of the Health Plan departments and other agencies with which providers most often interact. Contact List Name Comments Telephone No. Fax No. Registration can be done online. Review a member s eligibility for benefits. Check claim status. excellusbcbs.com Update practice information. Member health benefit program Request a claim adjustment. requirements, claim status and many Excellus BlueCross Enter referrals other options are available when you BlueShield online Request a preauthorization. register for online access. Other information is available without View fee schedule information. registration. Review clinical editing. View pharmacy information View medical policies Compare hospital quality information Provider Service is available Monday through Thursday, 7 a.m. to 7 p.m., Fridays 9 a.m. to 7 p.m., Sat. 9 a.m. to 1 p.m. Provider Service, Central New York Region Most lines of business Child Health Plus Family Health Plus Federal Employee Program HMOBlue Option 1 (800) (800) (800) (800) (800) Provider Service, Central New York So. Tier Region Most lines of business Federal Employee Program 1 (800) (800) June

2 2.0 Administrative Information Excellus BlueCrossBlueShield Name Comments Telephone No. Fax No. Provider Service, Monroe Plan (Many Rochester and CNY So. Tier Region government program members) Provider Service, Rochester Region Provider Service, Utica Region 1099 Support Unit Behavioral Health Department Behavioral Health Prior Authorizations IP mental health/psychiatric hospitalization, IP chemical dependency, OP mental health (select products only), Psychological evaluation BlueCard BlueExchange (Web-based) CAQH (Council for Affordable Quality Healthcare) Care Calls CareCore Appeals (preservice only) Child Health Plus Family Health Plus Blue Choice Option/HMOBlue Option Managed Care Products Traditional Indemnity and PPO Federal Employee Program Most lines of business Child Health Plus Family Health Plus Federal Employee Program HMOBlue Option Questions regarding W-9 forms or 1099 information Inquire about case management services HMO, HMOBlue Option, Child Health Plus, Family Health Plus PPO, Traditional Federal Employee Program Monroe Plan 1 (800) (866) (800) (800) (800) (800) (800) (800) (800) (800) (877) (800) (800) (888) (800) (877) (585) (585) (585) Information on members from out-ofarea BlueCross BlueShield health 1 (800) plans Registration required for use. Providers may register directly from the Web site. For practitioner credentialing 1 (888) Support for members with asthma, coronary artery disease, depression, diabetes. Providers may call to refer. CareCore National, LLC Attn: UM Appeals 400 Buckwalter Place Boulevard Bluffton, SC (800) (866) (866) Case Management, Behavioral Health See Behavioral Health Department, above 2 2 June 2009

3 Participating Provider Manual 2.0 Administrative Information Name Comments Telephone No. Fax No. Case Management, Government Programs Case Management, Monroe Plan members Case Management, other programs Claim Status Claims Submission, Electronic Claims Submission, Paper CompassionNet Computer Sciences Corporation (CSC) (epaces Medicaid eligibility inquiries) Coordination of Benefits (COB) Credentialing, Central New York, CNY So. Tier and Utica Regions (credentialing questions only) To refer members of Child Health Plus, Family Health Plus, HMOBlue Option for case management To refer Monroe Plan members of Child Health Plus, Family Health Plus, Blue Choice Option and HMOBlue Option for case management To refer a member for case management CNY 1 (877) Rochester Region and CNYST See Monroe Plan below Utica Region 1 (800) (800) CNY and CNYST Regions 1 (800) TDD 1 (888) Rochester Region 1 (877) TDD 1 (800) Utica Region 1 (800) TDD 1 (888) Call Provider Service or use Web site or QuickLink (registration required) See ecommerce, below Excellus BlueCross BlueShield PO Box Rochester, NY Case management for children with life-threatening illnesses Institutional (Clinics, hospitals, etc.) Practitioner (MDs, Dentists) Professional (DME, non-mds) See Other Party Liability (OPL) New applicants Recredentialing (A-D) Recredentialing (E-K) Recredentialing (L-R) Recredentialing (S-Z) Central New York Region (315) CNY Southern Tier Region (607) Rochester Region (585) Utica Region 1 (877) (800) (800) (800) (315) (315) (315) (315) (315) (315) June

4 2.0 Administrative Information Excellus BlueCrossBlueShield Name Comments Telephone No. Fax No. Credentialing, Rochester Region (credentialing questions only) Credit and Collection (Address to return overpayments) CuraScript Pharmacy, specialty pharmacy for patientadministered and provideradministered medications Customer Service Departmental Appeals Board (HHS) (Medicare Advantage only) Disease Management ecommerce epaces (software for Medicaid eligibility inquiries) Fair Hearing (Medicaid managed care, Family Health Plus) New applicants Reappointments (A-K) Reappointments (L-Z) Excellus BlueCross BlueShield Credit and Collection 333 Butternut Drive Syracuse, NY Patient-administered - Provider-administered (585) (585) (585) (866) (866) Members call number on ID card. Department of Health & Human Services Departmental Appeals Board, MS 6127 Medicare Appeals Council Cohen Building, Room G Independence Avenue, SW Washington, DC See Case Management Electronic transactions including claim submittal, electronic remits, QuickLink 1 (877) access Fair Hearing New York State Office of Temporary and Disability Assistance PO Box 1930 Albany, NY Call Computer Sciences Corp. (585) (888) (888) (800) (518) Federal Employee Program (FEP) Health Coaching 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. CNY and CNYST 1 (800) Rochester 1 (800) Utica 1 (800) (800) TTY 1 (877) CNY and CNYST (315) Rochester (585) Utica (315) June 2009

5 Participating Provider Manual 2.0 Administrative Information Help Desk Name Comments Telephone No. Fax No. Resetting QuickLink sign-ons and passwords 1 (866) HIV Counseling & Testing NYSDOH Program 1 (800) 541-AIDS InfoCheck (Rochester only) Phone line available 24/7 except 5-6 a.m., M-Fri and Sunday midnight until 6 a.m. Monday Inpatient Admissions IPRO (NODMAR) IPRO (NOMNC) Medical Intake Medical Policy Coordinator Medical Specialty Medication Review Program Medicare Advantage Coding Review (Patient Inquiry Reports) Member Eligibility Member Grievances Monroe Plan National Provider Identifier (NPI) Enumerator May be used to check eligibility, benefits, referrals and claim status for managed care. Requires Provider NPI. Facility to notify Health Plan IPRO 1979 Marcus Ave 1 st Floor Lake Success, NY Fast Track Appeals for Notice of Medicare Non-Coverage Most referrals and prior authorizations (585) (800) CNY and CNYST 1 (800) Rochester 1 (800) Utica 1 (800) IPRO Helpline NODMAR 1 (800) TTY 1 (866) (888) TTY1 (866) CNY and CNYST 1 (800) Rochester Call Provider Service Utica 1 (800) (516) Questions and comments on medical policies. Call Provider Service for connection. To request prior authorization forms and specialty pharmacy information. 1 (800) (800) Excellus BCBS Medicare Division 165 Court St. (585) (800) Rochester, NY Call Provider Service, or use QuickLink or Web site (registration required) During regular business hours, call or After hours, call 1 (800) Available to visit Customer Service for the Medicaid (HMOBlue Option and FHP) members applicable program. only. See Provider Service and Case Management entries. [email protected] 1 (800) TTY 1 (800) NPI Enumerator PO Box 6059 Fargo, ND June

6 2.0 Administrative Information Excellus BlueCrossBlueShield Name Comments Telephone No. Fax No. OptionCare, specialty pharmacy for patientadministered and provideradministered medications Other Party Liability (OPL) (Coordination of Benefits) For Worker s Comp, No Fault, and to discuss primacy and review COB claims PCP Selection Form (CNY and Utica government program members) Pharmacy Help Desk Preauthorization Preauthorization, Imaging Studies (CT, MRI, MRA, PET, nuclear cardiology) Preauthorization, Physical Therapy and Occupational Therapy Privacy Officer Provider Advocate Unit Provider File Maintenance Provider Relations - Patient-administered - Provider-administered Central New York, CNY So. Tier and Utica Regions Traditional Indemnity Managed Care/PPO Rochester Region Call Provider Service - 1 (866) (866) (800) (877) Fax form for CHP, FHP and HMOBlue Option members to select or change PCP Questions, exceptions, prior authorizations Most services that require preauthorization Requests may be made via Web, fax or phone. Special form required for faxed requests. Web access from Health Plan Web site. Added visits only. For initial visits, use standard preauthorization number. For complaints regarding member privacy PO Box 4717 Syracuse, NY (866) (866) (800) Fax prior authorization 1 (800) forms 1 (800) CNY and CNYST 1 (800) Rochester 1 (800) (Managed Care) 1 (800) (Traditional and PPO) Utica 1 (800) (866) M-F 7 a.m. 7 p.m. 1 (866) (888) (888) (866) To update Provider Information, use online form or fax form, or mail fax form or letter on company letterhead. CNY, CNYST and Utica 1 (800) Rochester (585) See list of Provider Relations Representatives on Web site or contact Provider Service. 2 6 June 2009

7 Participating Provider Manual 2.0 Administrative Information QuickLink Quit For Life Name Comments Telephone No. Fax No. Referrals (May also use Web or QuickLink to request referrals) Specialty Pharmacy Sterilization and Hysterectomy Consent Forms (Medicaid & FHP) Taxonomy (to select appropriate taxonomy) Vaccines for Children program Medicaid managed care (HMOBlue Option & BlueChoice Option) and Child Health Plus only Web Security Help Desk Contact ecommerce for information about registration. Call Help Desk for resetting passwords or sign-ons. Smoking cessation program for eligible 1 (800) members. Representatives available M to Th., 8 a.m. to 5 p.m., F, 9 a.m. to 5 p.m. See CuraScript and OptionCare To request patient consent forms for sterilization or hysterectomy. Via Web CNY and CNYST 1 (800) Rochester 1 (800) Utica 1 (800) CNY, CNYST and Utica 1 (877) Rochester (585) (518) (518) To view a complete list of taxonomy codes, go to the following Web site: M to F, 6:30 a.m. to 5:30 p.m. 1 (800) (518) (800) Obtaining Member Information from the Health Plan (518) The privacy rights of members are very important to the Health Plan, as is the Health Plan s relationship with participating physicians and other health care providers. The Health Plan has procedures in place to ensure that only properly authorized parties have appropriate access to members' protected information. In addition, the Health Plan has implemented a process that places extra emphasis on protecting confidential patient information. Note: For more information about Health Plan policies regarding privacy and confidentiality, see the Introduction section of this manual. When a physician or other health care provider calls the Health Plan requesting information about a member, the provider will be required to answer a few questions before the Health Plan will release the information. First, the participating provider must confirm his/her identity by supplying a provider identification number. Next, the provider must confirm his/her relationship with the member by supplying the member s full name and ID number. If the provider is unable to provide the member ID number, the provider must supply at least one of the following, in addition to the member s name: (end) June

8 2.0 Administrative Information Excellus BlueCrossBlueShield - Patient birth date - A claim number or authorization number - Patient address - Name of primary physician (when applicable) Note: If the member is a Health Plan employee (or dependent of a Health Plan employee), the provider must supply the subscriber ID. If neither the provider s identity nor the provider/patient relationship can be confirmed, the Health Plan will not release the information. 2.3 Health Plan Connectivity Web Site The Health Plan s Web site, excellusbcbs.com, carries up-to-date information for members and providers. See the chart titled Contents of the Health Plan Web Site at the end of this section of the manual for a broad overview. The material presented on the Provider pages of the Health Plan s Web site is also available by calling Provider Service (see Contact List). Note: In case of a discrepancy between any material presented on the Health Plan s Web site and the up-to-date version of that material on file at the Health Plan, the latter version controls. Menu Options on the Provider Home Page Some of the menu options such as those listed below and available on the Provider page of the Health Plan s Web site are discussed in sections of this Participating Provider Manual. Online Services Check Eligibility, Claims, and Referrals Updating Practice Information Medical Policies Prescription Drugs Online Services: Web Site or QuickLink Participating providers with computers in their offices may obtain member and claim information as well as perform certain transactions via two different computer inquiry systems: the Health Plan s Web site or QuickLink. QuickLink is a dial-up method of gaining access to information. Providers must register to access information via the Web site or QuickLink. Providers who have registered for either option have access to: Check member eligibility and benefits Check claims or request an adjustment 2 8 June 2009

9 Participating Provider Manual 2.0 Administrative Information Manage referrals and preauthorization requests There are other transactions possible from the Web site, including billing resources such as electronic remittance. (See the Billing and Remittance section of this manual for information regarding electronic remittance and payment.) To Register for Web Access For Web access, providers may register directly from the Health Plan s Web site. Note: Facilities must complete an application that can be obtained from Provider Service (see Contact List). Go online to excellusbcbs.com. Select For Providers. Go to Register Now! and select the role that applies from the I am a... drop-down menu. Click GO. This will bring you to your specific registration page. Hospital accounts department, emergency department and urgent care facilities will be directed to complete a paper form and fax it to a specific fax number for ecommerce. The fax number is on the form. Participating practitioners must establish a Master Account. This account provides access to our online tools and allows for the management of staff access. You will be asked for your Excellus BCBS provider ID number. This is your P010 number. Once you enter your practitioner information on the Provider Registration pages, click Submit. ecommerce will establish the Master Account for those required to fax, and notify you when the account is ready. Allow up to five days. Once the Master Account is established, log on with your Username and Password and select the Online Services menu. Click on the Manage Staff Access link. This feature allows you to give staff members access to our online tools. To ensure that only authorized staff have access, staff account must be managed by the practitioner or office manager. You may create office staff accounts or delegate the task to the office manager. To delegate management of staff accounts, select Add Office Manager Account to create this account prior to adding staff accounts. You will be prompted to create a temporary password. Once this account is created, you or the office manager can add staff accounts or use the Delete Account option to remove access for employees who leave your organization. To Register for QuickLink For access via QuickLink, providers should contact ecommerce (see Contact List). To use QuickLink, the office must have a standard personal computer with communications software such as HyperTerminal. The following specifications are included in most PCs today: Personal computer Communications software such as HyperTerminal Baud: 2400 bps 56k band Data bits: 8 June

10 2.0 Administrative Information Excellus BlueCrossBlueShield Duplex: full Terminal emulation: VT100 (including F5 F12) Parity: none Stop: 1 Port: default Electronic Billing The Health Plan is compliant with guidelines from the Centers for Medicare & Medicaid Services (CMS) regarding the HIPAA EDI Transaction and Code Set regulation and is prepared to receive HIPAA-compliant transactions. Contact ecommerce for more information about electronic billing Hospital Comparison Tool The Health Plan makes available through its Web site a hospital comparison tool. It is an online tool that compares the performance of selected hospitals on more than 175 procedures and medical conditions. The Health Plan offers access to the hospital comparison tool as a benefit to its members and providers. The tool allows the user to obtain an independent comparison of hospitals within a specific geographic area by procedure or diagnosis. Users may create a personalized report that compares hospital performance based on information hospitals provide to CMS, state health departments or local agencies. Use of the hospital comparison tool is completely anonymous. The generated reports provide an analysis of patients hospitalized for certain conditions, including the number of patients treated at each hospital (patients/year), the percentage of patients who developed problems (complications), the percentage of patients who died (mortality), the average number of days people stayed in each hospital (length-of-stay), and the average price the hospital charged. 2.4 Determining Member Eligibility for Benefits Before providing services, it is important to determine financial responsibility by verifying whether the patient has coverage for the service or should be treated as private pay. Participating providers may check member eligibility through the Health Plan s Web site, via QuickLink, or by calling the Health Plan. Providers must be registered in order to have access through QuickLink or the Web. For registration information, see the paragraphs above under Online Services. Member ID cards also contain valuable information, but it is still important to verify benefits before providing services Member ID Cards Each subscriber is assigned an identification (ID) number, and each member is eligible to receive his or her own ID card. Each of the Health Plan s health benefit programs has its own unique ID card. See the sample ID card at the end of this section of the manual. Sample ID cards for Child Health Plus, Family Health Plus and Medicaid managed care are in the Government Programs section of the manual June 2009

11 Participating Provider Manual 2.0 Administrative Information What to Look for on the ID Card Identification cards carry vital information to assist providers in doing business with the Health Plan. Provider offices should copy the front and back of ID cards, as both sides contain important information, including information providers need to submit claims and coordinate patient care. While our ID cards differ from product to product, there are some standard elements: Logo - The BlueCross BlueShield logo is on all BlueCross BlueShield plan identification cards. Suitcase logo Most BlueCross BlueShield ID cards include a logo that looks like an outline of a suitcase. This logo is an indication that providers should submit claims for a member from another BCBS health plan to the BCBS plan with which the provider participates. For example, if a provider participates with Excellus BCBS and provides services to a member from BlueCross BlueShield of Alabama, the claim should be submitted to Excellus BCBS. FLRx logo The FLRx logo indicates that the member either has prescription drug coverage through the Health Plan s pharmacy benefit manager (see the Pharmacy section of this manual) or is eligible for the FLRx Value-Add Prescription Drug Discount Program. Product Name -The name of the health benefit program (except for Child Health Plus and Family Health Plus which instead carry a group identifier of C or F, respectively). Subscriber Name This is the name of the person holding the policy. If the patient is a dependent, the patient s name may not be on the ID card. Identification Number The identification number is that of the subscriber. It is required on all claims. Most BlueCross BlueShield identification numbers include a three-letter prefix that must be included. Federal Employee Program subscriber IDs have a one-letter prefix (R). ID cards for Medicaid managed care and Family Health Plus members also include the member s Medicaid client identification number (CIN). Copay Amount(s). Telephone numbers. Address for paper claim submittal Member Eligibility Telephone Inquiry Before placing a call to the Health Plan, please have all required information, such as the patient s full name, subscriber ID and your NPI. Follow the prompts to select the correct options for your inquiry. Knowing the patient s type of coverage (indemnity, PPO, HMO, etc.) will help you choose the right options. Choosing the right options can decrease the time it takes to get the information you need. Limited benefit eligibility information is available via the Health Plan s interactive voice response telephone system. However, if you have selected the correct options and need to be transferred to a representative, you will more likely be transferred to a representative trained in the appropriate product line or service area. Because our subscriber ID numbers include an alpha character, you will be asked to speak the subscriber ID rather than key it in via the telephone keypad. Speak slowly and clearly and say zero rather than oh for the numeral. Do not include the three-character prefix. Use the BlueCard eligibility telephone line or BlueExchange (online) rather than IVR to check eligibility for out-of-area BlueCross BlueShield members. Call the appropriate FEP (federal employee program) service June

12 2.0 Administrative Information Excellus BlueCrossBlueShield line to check eligibility for federal employees. Contact information for BlueCard and FEP is on the Contact List. Rochester Region providers also have access to InfoCheck. See below for instructions for using InfoCheck InfoCheck Note: This option available to Rochester Region providers only. InfoCheck is a telephone inquiry system that providers can use for limited eligibility and benefit information, primarily about Blue Choice members. It is available 24 hours a day, seven days a week with two small exceptions: from 5 a.m. to 6 a.m., Monday through Friday and from Sunday at midnight until 6 a.m. Monday. See the Contact List for telephone numbers. Anyone calling in will hear the following message: This line is for providers only. If you are a member, press 1. Otherwise, remain on the line. After a brief pause to allow members to press 1, various options (described in the table on the following page) are available to the provider. 2.5 Health Plan Publications Participating Provider Manual The Health Plan s Participating Provider Manual is intended as a reference and source document for physicians and other providers who participate with the Health Plan. The manual is intended to clarify various provisions of a provider s participation agreement Provider Newsletter The Health Plan s provider newsletter, Connection, is an electronic publication that is issued and posted to the Health Plan s Web site on a monthly basis. The newsletter is designed to keep participating providers and their office staff apprised of developments in Health Plan policies and products. Each month, a link to the newsletter is ed to providers who have opted in to receive the publication electronically. To opt-in, providers must go to the Health Plan s Web site, and from the provider page, go to: Administration > News and Updates > Get Newsletter by . The newsletter notification will only be sent to those who have completed the opt-in process. If the provider s office does not have access to the Internet or does not wish to receive the newsletter electronically, they can receive paper copies via traditional mail. To request paper copies, please contact your Provider Relations representative June 2009

13 Participating Provider Manual 2.0 Administrative Information Menu Option Optical Benefits (Requires NPI, subscriber ID and member date of birth) Membership & Benefits (Requires NPI, subscriber ID and member date of birth) Blue Choice Referrals (Requires NPI, subscriber ID, member date of birth and Excellus BCBS PIN. Option 2 requires referral No. Not a method to generate a referral.) Blue Choice Claims Status (Requires NPI, subscriber ID, member date of birth and Excellus BCBS PIN. Info available only for Blue Choice claims.) InfoCheck Options (Rochester Region providers only) To access option Information available Date of last eye exam Routine eye exam benefit Press 1 Date of last eyewear purchase Routine eyewear benefit Cataract surgery eyewear benefit Non Blue Choice contracts Contract type Suffix number Blue Choice contracts Contract type Press 2 Name, suffix and effective date of individual on contract PCP / Alt PCP name and office visit copay Specialist office visit copay Mental health office visit limits and copay Chiropractor office visit copay Press 3 Press 4 Verify existing referral information only. Cannot generate referral via InfoCheck. Claim number, procedure code, diagnosis code Date paid or denied and, if paid, the amount by procedure code Transfer to Blue Choice Press 5 During business hours, this transfers the caller to a Blue Choice representative. Transfer to Blue Shield Press 6 During business hours, this transfers the caller to a Blue Shield representative. End call Press 9 Ends the call. June

14 2.0 Administrative Information Excellus BlueCrossBlueShield Ad Hoc Communications As needed, the Health Plan sends written notifications to participating providers regarding new and revised policies and procedures and other information of value. The Health Plan issues bulletins, letters and other notices in instances when notification is required outside the normal newsletter schedule, or when the information affects only a small, specific audience of providers. 2.6 Provider Office Environment Office Site Review The Health Plan may conduct site reviews of the office locations of physicians and other health care providers at initial credentialing and when a provider opens a new location. An office site review includes assessments of patient safety and privacy, office operations and confidentiality, appointment and accessibility, security of pharmaceuticals and prescription pads, and office record maintenance. The Credentialing Site Visit Checklist (included at the end of this section and on the Web site) lists the criteria Health Plan reviewers use during a site review. The Health Plan will conduct a site visit upon receiving two formal or informal complaints within 12 months. A complaint may be but is not limited to physical appearance, handicap access, waiting room or exam room space. Elements from the Credentialing Site Visit Checklist will be utilized for the visit. The areas to be reviewed include but are not limited to the following requirements on the checklist: Facility and Environment, Office Operations, Pharmaceuticals and Office Record Maintenance. All applicable standards must be met. Wheelchair Accessibility As part of the Office Site Review, Health Plan reviewers gather information to better serve members with disabilities. This information does not affect a provider s credentialing status. Accessibility information is included in Health Plan provider directories HIPAA Compliance Note: This section gives a general overview of HIPAA requirements. For information about Health Plan compliance with HIPAA standards on privacy and confidentiality, see the Introduction section of this manual. For information regarding HIPAA-compliant availability of eligibility, claims, and referral information, see paragraphs about Member Eligibility Remote Access Inquiry, Online Inquiry Systems, as well as referral and preauthorization information in the Benefits Management section of this manual. For information about Health Plan compliance with HIPAA standards on electronic submission of claims, see the Billing and Remittance section of this manual. The Health Insurance Portability and Accountability Act of 1996, Public Law , (commonly known as HIPAA), was designed to improve the efficiency and effectiveness of the health care system. It includes 2 14 June 2009

15 Participating Provider Manual 2.0 Administrative Information administration simplification provisions that require the U.S. Department of Health and Human Services to adopt national standards for electronic health care transactions. Recognizing that advances in electronic technology could erode the privacy of health information, Congress incorporated into HIPAA, provisions that mandate the adoption of federal privacy protections for individually identifiable health information. This information is referred to as Protected Health Information, or PHI. The HIPAA Privacy Rule provides standards for the protection of PHI in today s world where information is broadly held and transmitted electronically. HIPAA s privacy rule requires that health care providers and other specified entities ( covered entities ) take certain actions to maintain confidentiality. Some of these actions are: Notifying patients about their privacy rights and how their PHI can be used Adopting and implementing privacy procedures Training employees to understand privacy procedures Designating a Privacy Officer responsible for seeing that privacy procedures are adopted and followed Securing patient records containing PHI so they are accessible only to specified individuals Who Must Comply The following individuals and organizations must comply with the HIPAA standards. They are referred to as covered entities. Health care providers who electronically conduct the financial and administrative transactions listed under Applicable Transactions, below Health plans such as this Health Plan and Medicare and Medicaid, employer plans under the Employee Retirement Income Security Act (ERISA), Indian Health plans, and self-administered plans (except those with fewer than 50 participants) Health care clearinghouses Business associates of any of the covered entities, if the business associate has contracted to comply with HIPAA These covered entities are required to comply even if a third party conducts the specified transactions on their behalf. Applicable Transactions All covered entities that conduct any of the following standard transactions are required to use HIPAAcompliant electronic language and codes: Health care claims or equivalent encounter information Health care payment and remittance advice Coordination of benefits Health care claim status Enrollment and disenrollment in a health plan Eligibility for a health plan Health plan premium payments Referral certification and authorization June

16 2.0 Administrative Information Excellus BlueCrossBlueShield Compliance Dates Covered entities had until April 14, 2003, to comply with the act s privacy regulations. Covered entities were to have complied with HIPAA standards for electronic claim submission (ANSI 837) by October 16, 2003, subject to fine, although a one-year delay was granted to small organizations Updating Practice Information The Health Plan requires that providers submit updated information whenever there are any changes to a provider or his/her practice. This is necessary to keep directory and claims systems information current. This includes changes in: Provider Name Provider Tax ID Provider NPI Provider Taxonomy Codes Payment Address Directory Listing: that is, provider address, phone number, fax number and, for primary care providers who participate in managed care products, whether the practice is accepting new patients Service Addresses Changes in coverage arrangements When one or more practitioners join the group practice When one or more practitioners leave the group practice To notify the Health Plan of such changes, complete a Provider Information Update Form, indicating what information has changed. A sample form is provided at the end of this section. The form is also available from the Provider page on the Health Plan s Web site. Select Administration from the menu bar at the top, then click on Update Practice Information Update in the menu on the left. At this point, chose either the online or paper form. The online form requires the provider to log on. The completed paper Provider Information Update Form may be faxed or mailed to Provider File Maintenance. Address and fax number are included on the form. Note: Providers also may notify the Health Plan of changes in practice information by submitting a letter, on office letterhead, specifying what the changes are. Letters also should be faxed or mailed to Provider File Maintenance. If a practitioner who is not already participating is joining a currently participating group practice, the Health Plan also requires that provider to complete an Initial Practitioner Information Form, also available via the Health Plan s Web site. To get to the form from the provider page of the Web site, go to: Administration > Print Forms and Templates > Credentialing. A sample form is provided at the end of this section Closing/Opening a Practice In signing a participation agreement with the Health Plan, a participating physician agrees to accept as patients those members who elect to receive care from the physician, or those whom the Health Plan 2 16 June 2009

17 Participating Provider Manual 2.0 Administrative Information assigns to the physician. If the physician s practice is at capacity, the physician may close his/her practice to new managed care patients. However, a participating physician shall not close or reopen his/her practice to new patients without giving the Health Plan 90 days prior written notice. In all cases, a participating physician shall continue to permit a current patient who has other health coverage to designate the physician as his/her PCP in the event the patient chooses to enroll as a member of the Health Plan Access to Care The Health Plan has established appointment availability standards to provide reasonable patient access to care. In addition, physicians who participate in the Health Plan s managed care programs are required to advise the Health Plan in writing of covering participating physician arrangements or changes to those arrangements, including situations in which physicians in the same office are covering for each other. See the Quality Improvement section of this manual for additional information about the Health Plan s requirements for accessibility, including access to after hours care Member Payments Except in limited circumstances (see paragraphs headed Charging for Copying of Medical Records, and Patient Financial Responsibility Agreement), Health Plan participating providers cannot charge and/or collect a deposit from or seek any form of reimbursement from a Health Plan member, or persons acting on the member s behalf, other than the permitted copayments, coinsurances, or deductibles associated with covered services. Note: Cost-sharing information (copayments, coinsurance and deductibles) for specific member contracts is available via the QuickLink and the Web site inquiry methods. Providers may also call Provider Service for this information. Charges Not Permitted Participating providers cannot: Bill a managed care member for services, unless the member has selected the provider as his/her PCP or the member has a valid referral from his/her PCP to see the provider. To charge a member in limited circumstances (non-covered services), the member must have signed a valid Patient Financial Responsibility Agreement (see below) or other waiver. Charge a member when the member is covered by two health plans. For example, if the Health Plan is primary and a balance remains after the Health Plan has reimbursed its allowed amount for covered services, providers must bill the secondary carrier. Charge a member for administrative fees, such as completing claims forms or triplicate prescriptions that are standard overhead costs. Providers may bill a member if the member fails to show up for an appointment, but only if this policy is prominently displayed in the office and communicated to the physician s patients. The Health Plan does not pay for missed appointments. June

18 2.0 Administrative Information Excellus BlueCrossBlueShield Patient Financial Responsibility Agreement The Health Plan encourages participating providers to ascertain, prior to supplying services to a Health Plan member, whether those services are covered under the member s health benefit program. (See previous paragraphs for information about determining member eligibility.) This is important because, as stated above, participating providers may not charge or collect a deposit from or seek any form of reimbursement from a Health Plan member, or a person acting on the member s behalf, other than the permitted copayments, coinsurances, or deductibles associated with covered services. Providers must notify the member in writing prior to providing a service that is not covered informing the member that he/she will be liable for payment. In situations where a member does not have a valid referral, or the member s eligibility for requested outpatient services cannot be determined because the Health Plan s member eligibility systems are not available, participating providers may elect to have the member complete and sign a Patient Financial Responsibility Agreement. (A sample form is available on the Health Plan Web site or from Provider Service.) Having the member sign the form may allow the provider to bill the member for services that the Health Plan did not cover because: The managed care member self-referred for the service, or The services were not a covered benefit under the member s benefit package, or The services were not within the scope of the provider s participation agreement, or The member had not completed the required waiting period for treatment of a pre-existing condition. Once a member has signed a Patient Financial Responsibility Agreement, the provider should keep the form on file. 2.7 Medical Records The Health Plan requires that participating provider medical records be kept in a manner that is current, detailed, organized, that complies with all state and federal laws and regulations, and that is accessible by the treating provider and the Health Plan. To support this requirement, the Health Plan has established Medical Record Documentation Standards. Information regarding these standards is included in the Quality Improvement section of this manual Access to Medical Records By the Health Plan A participating physician or other provider must maintain medical records and provide such medical, financial and administrative information to the Health Plan as it may reasonably require to ensure compliance with applicable laws, rules, and regulations; and for program management purposes. Participating physician offices must: 2 18 June 2009

19 Participating Provider Manual 2.0 Administrative Information Maintain medical records in a manner that is individualized, current, organized, detailed, and confidential. Make records available to Health Plan staff for review when requested. Provide copies of patient charts to the Health Plan without cost, per the provider s participation agreement. Note: Medical record documentation auditing and reporting are part of health care operations as defined by HIPAA and thus do not require patient authorization for release of protected health information. For information about HIPAA, see the paragraph headed HIPAA Compliance that appears earlier in this section of the manual. By Members Members have the right to see their medical records. The Health Plan member handbooks state that any requests for medical records should be directed, in writing, to a member s physician. Each member age 18 or over, or an emancipated minor, must sign his or her own written request Charges for Photocopying Medical Records Subject to the terms of a provider s participation agreement, a participating provider may not charge the Health Plan or the Department of Health for photocopying a patient s medical record. New York State Public Health Law Article 1, Title 2, Section 18 (2.e) states that providers may impose reasonable charges when a patient (subject) requests copies of his/her medical records, not to exceed 75 cents per page. However, members may not be denied access to their records due to inability to pay Advance Care Directives The Health Plan encourages providers to discuss with members end-of-life care and the appointment of an agent to assume the responsibility of making health care decisions when the member is unable to do so. Information for members about advance care planning is available on the Health Plan s Web site. The Health Plan s Medical Records Documentation Standards state that medical charts must include documentation indicating that adults age 18 years and older, emancipated minors, and minors with children have been given information regarding advance directives. See the Quality Improvement section of this manual for additional information about this requirement and about advance care directives. Note: Treatment decisions cannot be conditional on the execution of advance directives. 2.8 BlueCard Program The BlueCross BlueShield Association sponsors the BlueCard Program, a program that helps make it possible for members covered by affiliated BlueCross BlueShield plans to maintain the protection of BlueCross BlueShield coverage even when they are away from the area served by their home plan. June

20 2.0 Administrative Information Excellus BlueCrossBlueShield Most BlueCross BlueShield members have a three-letter alpha prefix at the beginning of the member identification number. This prefix is critical to identifying the member s home plan and must be included on all claims. In addition, a suitcase logo located on member s identification card indicates that the claim for the out-of-area member should be submitted to the plan with which the provider participates (i.e., Excellus BCBS) 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. Prefix is the three-letter alpha prefix in front of the member identification number. The prefix is critical to identifying the member s home plan and expediting claim processing Contacting the Home Plan Providers should contact the Home Plan for the following: Membership Benefits Member cost-sharing amounts Referrals and authorizations There are two ways to contact the Home Plan. BlueExchange. BlueExchange is the BlueCross BlueShield interplan system for select HIPAA transaction processing, including checking eligibility, checking claim status and requesting referrals. BlueExchange uses standard formats, secure and reliable plan-to-plan communications, common validation processes, and performance measurements. Providers can access BlueExchange via the Health Plan s Web site or QuickLink. (See the paragraphs regarding online inquiry systems.) BlueCard 800# network. Providers may call the BlueCard toll-free telephone number (see Contact List) to be routed to the member s Home Plan, after providing the alpha prefix BlueCard Rules A provider who participates with a local BlueCross BlueShield plan for indemnity, PPO, EPO, POS and Medicare Advantage products is also a participating provider for out-of-area BlueCross BlueShield members with these products. (See the Introduction section of this manual for definitions/descriptions of these types of products.) For HMO plans, an out-of-area authorization must be obtained from the member s plan in order for services to be covered (except for emergency services). There may be some exceptions to this policy, based on the member s contract. Workers Compensation and No Fault claims cannot go through BlueCard. For these claims, the provider must submit directly to the patient s Home Plan June 2009

21 Participating Provider Manual 2.0 Administrative Information Providers may submit all other claims to their local BlueCross BlueShield plan just as they would claims for locally enrolled subscribers. Providers must bill all BlueCross BlueShield claims, including BlueCard claims, with the three-letter alpha prefix. The letters in the prefix indicate the patient s Home Plan Contact Local Plan for BlueCard Claim Inquiries There are three options for claim inquiries. Use BlueExchange via the Health Plan s Web site or QuickLink. Use the paper adjustment form provided by the Health Plan. (See the Billing and Remittance section of this manual.) Call the Health Plan s Provider Service unit (see Contact List). 2.9 Samples, Forms and Charts These samples, forms and charts are reproduced on the following pages: Chart: Contents of the Health Plan Web Site Sample: Member ID Card Chart: Credentialing Site Visit Checklist Form: Provider Information Update Form (3 pages) Form: Initial Practitioner Information Form (3 pages) June

22 2.0 Administrative Information Excellus BlueCrossBlueShield For Providers For Members For Employers For Guests For Brokers Contents of the Excellus BlueCross BlueShield Web Site excellusbcbs.com Online Services: Member Eligibility, Benefits, Claims, Referrals, Admissions, Preauthorizations, Access a Patient s Health Record, Compare Hospital Quality, Manage Staff Access Patient Care: Health Promotion & Prevention, Managing Illness, Behavioral Health, Quality & Performance, Medical Policies, Clinical Practice Guidelines, Clinical Tools, Health Care Planning Administration: Fee Schedules, Billing Resources, Physician Advisory Committee, Print Forms and Templates, Provider Directories, Update Practice Information, Credentialing, Provider Manuals, Glossary, News and Updates Prescription Drugs: Check Our Drug List, Drug Management Programs, Prescribing Support, Help Patients Save Money, Patient Educational, Find a Pharmacy, Prior Authorization Forms Contact Us: Contact Us, About Us, News Room, Health Policy & Research, Compliance Notices My Account: Change Your Doctor, Change Your Address/Phone, Request ID Card, Print Forms, Manage Your Policy, Enroll in a New Policy, Share Your Protected Health Information, View Electronic Documents, Flexible Spending Account, News and Updates Health & Wellness: Healthy Rewards, Manage Your Health, Healthy Living, Help With Illness, Quality & Safety, Planning for Future Needs, Editorial Policy Health Plans: Blue On Demand, Health Plans, Medicare Plans, Dental Plans, Seeking Care, BlueCard Program, BlueCard Worldwide, Frequently Asked Questions Prescription Drugs: Check Our Drug Lists, Save Money on Your Prescriptions, Find a Pharmacy, Manage Your Medications, View Your Drug Claims, Medicare Drug Plan Information, Educational Materials Find a Doctor or Hospital: Find a Doctor, Find a Dentist, Find a Hospital, Compare Hospital Quality, Find a Pharmacy, Find a Cancer Treatment Center, Find an After Hours/Urgent Care Center, Find Other Providers Information for employers that offer Health Plan products to employees. Includes the following: Policy Manager, Health & Wellness, Health Plans, Prescription Drugs, Employer Resources Information for guests (individuals who may be looking for coverage) includes the following: Health Plans, Health & Wellness, Prescription Drugs, Find a Doctor or Hospital Information for brokers who sell Health Plan products. List subject to change June 2009

23 Participating Provider Manual 2.0 Administrative Information Sample Member ID Card Information may vary in appearance or location on the card, but all cards display basically the same information (such as product name, member name and ID number, customer service telephone number, claims address, etc.). Other information on the card, such as prior authorization requirements or other telephone numbers, may be specific to the Health Plan product under which the member has coverage. HealthyBlue Sample ID Card Copay and Deductible Option HealthyBlue Member Name Member ID You are enrolled in a PPO Product. Dependents are not listed on PPO ID cards. No referrals are required. BIN Effective Date Plan Code /00/00 302/802 Plan PCP Copay Children up to age 19 Specialist Copay Emergency Deductible PPO $XX $0 $XX $XXX $XXX/$XXXX Front of HeathyBlue Member ID Card Rx Customer Service: Prior Authorization Requirements Certain services require prior authorization. Please visit our Web site or call the number at the right to confirm if a service requires prior authorization. Hospital or physicians: file claims with local BlueCross and/or BlueShield Plan. Pharmacy Benefit: Prior Authorization: Excellus BlueCross BlueShield PO Box Rochester, NY A nonprofit independent licensee of the BlueCross BlueShield Association Pharmacy benefits administrator Back of HealthyBlue Member ID Card June

24 2.0 Administrative Information Excellus BlueCrossBlueShield Credentialing Site Visit Checklist The Health Plan may perform an office site review as part of the provider credentialing/recredentialing process for PCPs, OB/GYNs and behavioral health providers. Provider sites must meet the following standards or have a corrective action plan in place for the credentialing process to proceed. Facility and Environment ο Clean, private restroom for patients* ο Waiting and treatment rooms clean, sanitary and of adequate size* ο Patient care areas ensure privacy* ο Handicap accessible* Office Operations ο Confidentiality policy for staff* ο Process to identify and contact patients who miss appointments Access to Care ο Emergency coverage, 24 hours a day, seven days a week ο Urgent medical care available within 24 hours ο Adult base-line medical exam available within 12 weeks ο Routine health maintenance care within four weeks ο Non-urgent sick visits within 48 to 72 hours ο Well-child visits within four weeks ο Routine behavioral health care within 10 business days ο Urgent behavioral health care within 48 hours Pharmaceuticals ο Medications and supplies stored in secure location* ο Prescription pads stored in secure location* Office Record Maintenance ο System in place to ensure a neat and legible record for each patient ο Patient name, ID number on each page, all entries dated, sequential and signed or initialed by author ο Problem list included ο Office records stored securely to maintain confidentiality and privacy* ο Records kept for individual patients ο Records maintained for period required by law ο System in place to ensure that provider reviews all clinical information ο Allergies displayed prominently ο System to capture biographic and personal data and appropriate medical history * Asterisked items are reviewed upon complaint. Rev. 7/ June 2009

25 Provider Information Update Form A nonprofit independent licensee of the BlueCross BlueShield Association Instructions: Please complete this form and return by mail or fax to the addresses shown on the last page. This form must be personally signed by the provider (no signature stamps can be accepted). 1) Provider Name: 2) Provider's Tax ID Number: individual number group number If this is a group number, what is the name of the group? 3) Provider's License Number: State Issued 4) NPI (National Provider Identifier) Number(s) for: Individual Provider NPI (Type 1): Group Entity NPI (Type 2): Group Name: Group Entity NPI (Type 2): Group Name: 5) Taxonomy Code for: Primary Specialty: Taxonomy Code: Second Specialty: Taxonomy Code: Third Specialty: Taxonomy Code: ***For the remaining questions, fill out only the ones that require a change or update to your information *** 6) Address Change: (please check appropriate box) Street Address Suite/Bldg # Address/telephone change Additional location/telephone City State ZIP Code County Terminating location/telephone Phone ( ) Fax ( ) Termination date of location/telephone Billing Address/Telephone change Effective date of new address Office Physician Handicap accessible? Yes No Accessible to public transportation? Yes No Old Address: (if address change checked) Street Address Suite/Bldg # City State ZIP Code County Phone ( ) Fax ( ) Office Physician 7/08

26 7) Is the tax ID listed above a change? Yes No (If yes, attach a copy of W-9 Form Paper only) Effective date of new tax ID # What is the Old tax ID # 8) What hours are you available to see patients? (For more than 2 locations, please attach an additional sheet Paper only) Location 1: Location 2: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Office Start Office End Office Start Office End Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9) Are you accepting new patients? Yes No 10) For Primary Care Physicians Only List names of on-call physicians below (attach additional sheet if necessary Paper only) Name Effective Date Cross Cover? Yes No Yes Yes Yes Yes Yes No No No No No 11) What languages are spoken by practitioners and clinical personnel in this office? 12) Hospital affiliations: Hospital Name Hospital Address 7/08

27 13) Do you have a nurse practitioner or physician's assistant who works with you? Yes No If yes, please list below. Name NP or PA Effective Date NP PA NP NP NP PA PA PA 14) Additional comments: Practitioner's signature required Date (stamps not acceptable) Please mail or fax this completed form to the address below that is located closest to your primary office: For Rochester area: For CNY, Southern Tier & PA areas: For Utica/Watertown & VT areas: Excellus BlueCross BlueShield Excellus BlueCross BlueShield Excellus BlueCross BlueShield Provider File Maintenance Provider File Maintenance Provider File Maintenance 165 Court Street 333 Butternut Drive 12 Rhoads Drive Rochester, NY Syracuse, NY Utica, NY Fax Number: (585) Fax Number: (800) Fax Number: (800) /08

28 Initial Practitioner Information Form A nonprofit independent licensee of the BlueCross BlueShield Association. To begin your enrollment process, please use this simple, standardized form. Please complete all information as it applies to your specialty. Information that does not apply to your specialty may be left blank. DATE: Last Name: First Name: Middle Initial: Date of Birth: Gender: Male Female Primary Telephone No.: ( ) - Primary Fax No.: ( ) - Primary Office Street Address: Suite #: Primary Office City: State: County: Zip: - Address: Social Security No.: State License No.: DEA Certificate No.: Licensed State: UPIN (if applicable): Tax ID: Group Tax ID: Provider Type (MD, DO, DC, DDS, DMD, DPM, etc) : Primary Specialty: Second Specialty: Third Specialty: Taxonomy Code: Taxonomy Code: Taxonomy Code: Applying As: PCP Specialist Allied/Consulting Health Professional Are you board certified? Yes No If Yes, board name: Are you registered with CAQH? Yes No If Yes, CAQH Provider ID: NPI number: Name of Group or Employer (if applicable): Group Number: Effective date of group affiliation: Group NPI Number: Other NPI Number: 6/09

29 Is Main Office Address Handicap-accessible? Yes No Second Office Address (if applicable): Street Address: City: County: State: ZIP Code: - Office Phone: ( ) - ext. Office Fax: ( ) - Is Second Office Address Handicap-accessible? Yes No Billing Address: Street Address: City: County: Medicare No.: Medicaid No.: State: ZIP Code: - Phone: ( ) - ext. Fax: ( ) - What languages other than English do you speak? Workers Compensation No.: CLIA Cert No.: Hospital affiliations: Hospital Name Hospital Address Office Contact Person Name: Phone: ( ) - ext. Note: If you have already completed your application with CAQH, please ensure that you have authorized all applicable organizations to access your data. Using the CAQH Universal Credentialing DataSource does not grant participation or constitute applying for participation with any of the above organizations. If applicable, please contact the health plan directly to request contracting information. Signature of person completing form: Title: Date: PLEASE ATTACH W-9 FORM, COPY OF LICENSE, AND A COPY OF AGREEMENT SIGNATURE PAGE WITH THIS INFORMATION. ENROLLMENT WILL NOT BE PROCESSED WITHOUT THIS DOCUMENTATION. 6/09

30 Please return this form by mail or fax to the applicable Network Management office: Rochester: Excellus BCBS Rochester Region, Attn: Network Management Address: 165 Court Street, Rochester, NY Fax: Utica: Excellus BCBS Utica Region, Attn: Provider Relations Address: 12 Rhoads Drive, Utica, NY Phone: Contact your assigned Provider Relations representative Fax: Syracuse: Excellus BCBS CNY Region, Attn: Network Management Address: 333 Butternut Drive, Syracuse, NY Fax: Southern Tier: Excellus BCBS Southern Tier Elmira Office: Address: 150 North Main Street Suite 1, Elmira, NY Phone: Fax: Not Available Binghamton Office: Address: 53 Chenango Street, Binghamton, NY Phone: Fax: Not Available 6/09