WHAT S INSIDE? Assistant Surgeon Payment Differential Reminders 2 Medicare Crossover Claim Submission Reminder 3 Fighting Health Care Fraud, One Call at a Time 3 Meet Your Ancillary Provider Network Consultant (PNC) 4 Professional PNC Assignments 4, 5 First Quarter 2014 Pharmacy Optimization Initiative Highlights 6 Pharmacy Program Changes Effective April 1, 2014 6 Central States Teamsters Adds New Members 7 REVIEWSM FOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS A Closer Look: Documentation and Coding for Behavioral Disorders APRIL 2014 In this month s issue of Blue Review, we are taking a closer look at behavioral health disorders. Behavioral health disorders are usually categorized by intense alterations in thinking, mood and/or behavior over time and can be difficult to diagnose as they are often accompanied by multiple and similar symptoms. While the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 ) is used to assess and diagnose the patient, the ICD-9-CM coding system is required for reimbursement. It is critical for coding staff to understand mental illness terms as many terms are closely related. If there is ambiguity in the meaning of a term or title description, best practice for coding staff may be to query the provider for clarification. GENERAL DOCUMENTATION TIPS To obtain an accurate and complete picture of a patient s health status, clinical documentation should include the following information: Reason for encounter and medical history Prior diagnostic test results Assessment, clinical impression and diagnosis Plan for care Date, name and credentials of clinician Reason for diagnostic and ancillary services Health risk factors (e.g., alcohol and drug use, diet, sleep patterns) SCHIZOPHRENIC DISORDERS Schizophrenic disorders are characterized by disturbances in thought, mood, sense of self; bizarre, purposeless behavior, repetitious activity, or inactivity. 1 Clinical documentation should include the type and clinical status of the disorder which is required for selection of the appropriate diagnosis code. ICD-9 requires a fourth digit to identify the type of schizophrenic disorder and a fifth digit to specify the clinical status. The clinical status is noted as Subchronic, Chronic, Subchronic with Acute Exacerbation, Chronic with Acute Exacerbation, and in Remission. Listed below are ICD-9 codes associated with Schizophrenic disorders: 295 Schizophrenic Disorders 295.0x Simple Type 295.1x Disorganized Type 295.2x Catatonic Type 295.3x Paranoid Type 295.4x Schizophreniform Disorder 295.5x Latent Schizophrenia 295.6x Residual Type 295.7x Schizoaffective Disorder 295.8x Schizophrenia other specified types 295.9x Unspecified Schizophrenia In ICD-10, schizophrenia has two categories: F20 schizophrenic disorders and F21 schizotypal disorders. Schizotypal disorders are characterized as personality disorders in which a person has trouble with relationships and disturbances in thought patterns, appearance and behavior. 2 The F20 category requires a fourth digit to identify the schizophrenia type. Sub-category F20.8, other schizophrenia, requires a fifth digit to further define the condition. Code F20.81, schizophreniform disorder, is borderline schizophrenia disorder, not present for the full time required to diagnose schizophrenia; code F20.89, other schizophrenia, classifies all other schizophrenia types not identified by a fourth digit, for example, cenesthopathic schizophrenia or simple schizophrenia. F20.0 Paranoid Schizophrenia F20.1 Disorganized Schizophrenia F20.2 Catatonic Schizophrenia F20.3 Undifferentiated Schizophrenia F20.5 Residual Schizophrenia F20.8x Other Schizophrenia (requires a fifth digit) F20.9 Unspecified Schizophrenia (continued on p. 2) VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
Assistant Surgeon Payment Differential Reminders The following non-physician surgical assistants are eligible for participation as independent contractors in the Blue Cross and Blue Shield of Illinois (BCBSIL) PPO network: Certified Surgical Assistant (CSA) Certified Surgical Technician (CST) Registered Nurse First Assist (RNFA) Registered Surgical Assistant (RSA) Surgical Assistant Certified (SA-C) Please note that this is not an all-inclusive list. As a reminder, assistant surgeon services performed by a CSA, CST, RNFA, RSA or SA-C must be reported with the Current Procedural Terminology (CPT ) Modifier AS. Reimbursement for these allied health professionals is based on the payment level of 85 percent of the 20 percent of the applicable fee schedule for the given CPT code billed. For additional information, visit the Network Participation section of our Provider website at bcbsil.com/provider. CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. A Closer Look: Documentation and Coding for Behavioral Disorders (continued from p. 1) EPISODIC MOOD DISORDERS Bipolar Disorders and Major Depressive Disorder (MDD) are considered episodic mood disorders. Episodic mood disorders are conditions categorized by periods of depression, sometimes alternating with periods of elevated mood. 3 Bipolar disorder includes mania and depression while major depressive disorder is a stand-alone diagnosis. A required fourth digit in ICD-9 identifies the episodic mood disorder type and the episode. 296.0x Bipolar Disorder, single manic episode 296.1x Manic Disorder, recurrent episode (bipolar disorder) 296.2x Major Depressive Disorder, single episode 296.3x Major Depressive Disorder, recurrent episode 296.5x Bipolar I Disorder, most recent episode (or current) manic 296.6x Bipolar I Disorder, most recent episode (or current) depressed 296.7x Bipolar I Disorder, most recent episode (or current) unspecified The fifth-digit classification identifies the severity or the clinical status. If the episode is recent or current, the severity is noted; otherwise, the fifth digit indicates the current clinical status. 0 Unspecified 1 Mild 2 Moderate 3 Severe without psychotic behavior 4 Severe with psychotic behavior 5 In partial remission or unspecified remission 6 Full Remission Documentation for depression requires a specific level of detail because there are two types: situational and chemical. Situational depression arises from life circumstances that impact the individual such as a traumatic event or death in the family. Chemical depression is caused by chemical abnormalities in the brain and is treated mainly with drugs. Based on the medical record documentation, situational depression codes to ICD-9 code 311 and major depressive disorder codes to either 296.2x or 296.3x. However, in ICD-10 there is no distinction between depression not otherwise specified (NOS) and major depressive disorder. Both descriptive titles fall under one ICD-10 code, F32.9. ICD-10 has six categories for episodic mood disorders: F30 Manic Episode F31 Bipolar Disorder F32 Major Depressive Disorder, Single Episode F33 Major Depressive Disorder, Recurrent F34 Persistent mood (affective) disorders F39 Unspecified mood (affective) disorder The fourth digit in ICD-10 further specifies symptoms associated with the current episode. The fifth digit identifies the severity or the clinical status. DELUSIONAL DISORDERS Delusional disorders are characterized by the presence of non-bizarre delusions which may persist for at least one month. 4 In ICD-9, the required fourth digit identifies the type of delusional disorder and there is no fifth-digit assignment. 297.0 Paranoid State, simple 297.1 Delusional Disorder 297.2 Paraphrenia 297.3 Shared Psychotic Disorder 297.8 Other Specified Paranoid States 297.9 Unspecified Paranoid State In ICD-10, delusional disorders are under one category (F22) and there is no fourth- or fifth-digit assignment. Shared psychotic disorder does not fall under the delusional disorder category; rather it has its own category, F24. References 1 International Classification of Diseases, 9th edition, Clinical Modification 2 National Library of Medicine. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/001525.htm 3 International Classification of Diseases, 9th edition, Clinical Modification 4 Diagnostic and Statistical Manual of Mental Disorders, 4th edition. DSM and DSM-5 are registered trademarks of the American Psychiatric Association. Note: This material is provided for informational purposes only and is not an endorsement of any particular site or resource. The owners/operators of each website are solely responsible for the content on their respective websites. This material is for educational purposes only and is not intended to be a definitive source for what codes should be used for, any particular disease, treatment or services. Health care providers are instructed to submit claims using the most appropriate code based upon the medical record documentation, coding guidelines and reference materials. 12 VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
Medicare Crossover Claim Submission Reminder Fighting Health Care Fraud, One Call at a Time Each year, our Fraud Hotline receives thousands of calls reporting possible health care fraud and abuse. The BCBSIL Special Investigations Department (SID) actively reviews every call to determine if the information presented meets guidelines for fraud and abuse. If there is a question of fraud, preliminary interviews and field audits may be conducted to determine if fraud was intentionally committed. If SID concludes that there was no act of fraud, the case may be referred to the appropriate business area, which may offer guidance to resolve the issue. As referenced in the March 2014 issue of Blue Review, Blue Cross and Blue Shield Plans have been using the Centers for Medicare & Medicaid Services (CMS) crossover process to receive Medicare primary claims since January 2006. The CMS crossover process routes Medicare Supplemental claims (Medigap and Medicare Supplemental) directly from Medicare to BCBSIL so that providers do not need to also submit the claim to BCBSIL. Over the years, this Medicare crossover process has helped increase efficiency by requiring only one claim submission, reducing duplicate submissions, improving payment accuracy, and increasing member and provider satisfaction. Although the above process has been in existence for over eight years, providers have continued to submit the claim to both Medicare and BCBSIL resulting in duplicate claims. These duplicate claims result in additional, unnecessary work and possible inaccurate claims processing, which in turn has a negative impact on providers, members and Plans. When the Home Plan receives a Medicare Primary claim before it is crossed over, it may be incorrectly paid based on an estimated Explanation of Medicare Benefits (EOMB). Provider payment should be calculated based on the actual EOMB. Members are also impacted when providers submit duplicate claims. When the Home Plan uses an estimated EOMB, they may incorrectly calculate member cost sharing. In an effort to improve the Medicare crossover administrative process, all providers are instructed to follow new rules concerning Medicare secondary claim submission. CMS requires that when a Medicare claim has been crossed over, providers are to wait 30 calendar days from the initial Medicare remittance date before submitting the claim to BCBSIL. BCBSIL will reject provider-submitted claims when Medicare is considered primary, including those with Medicare-exhausted benefits that have crossed over, if they are received within 30 calendar days of the initial remittance date or with no Medicare remittance date. It is expected that this modification will help address duplicate claim submissions. For additional information, including answers to frequently asked questions, look for the extended article in the News and Updates section of our website at bcbsil.com/provider. There are cases in which hotline reports have led to recovery efforts for inappropriate payment of claims and reimbursements or to law enforcement for criminal prosecution. Some of the most egregious cases leading to criminal prosecutions have stemmed from hotline calls. The evidence is clear: Each call or report can make a difference in the fight against fraud and abuse. Health care fraud affects all of us, so please report your suspicions of fraud to the SID. The following resources are available 24 hours a day, seven days a week for reporting suspected fraud and abuse: Phone Call the BCBSIL Fraud Hotline: 877-272-9741. (All calls are confidential and may be made anonymously.) Online Visit the Fraud and Abuse page in the Education and Reference Center section of our website at bcbsil.com/provider where you will find more information and a link to file a report online. U.S. Mail Report fraud by mailing your correspondence to SID at: BCBSIL, Attn: Special Investigations Department, 300 East Randolph Street, 35th Floor, Chicago, IL 60601. APRIL 2014 3
Meet Your Ancillary Provider Network Consultant (PNC) BCBSIL contracts with more than 2,000 independent ancillary providers in Illinois and Northwest Indiana. Our Ancillary PNC focuses specifically on the services provided by Skilled Nursing Facilities, Home Health Agencies, Hospice, Home Infusion Therapy, Durable Medical Equipment suppliers, Orthotics and Prosthetics, Dialysis Centers and Private Duty Nursing agencies. The following Ancillary PNC is available to meet with you and your staff regarding BCBSIL policies and procedures, billing and contractual issues: Elaine Williams, 312-653-4305 You may also direct your requests and inquiries to our general email box at ancillarynetworks@bcbsil.com, or leave a message at 312-653-4820. Professional PNC Assignments (Revised April 2014) Our PNCs serve as the liaison between BCBSIL and our independently contracted professional provider community, developing and maintaining cooperative working relationships with professional providers in our network throughout Illinois and Northwest Indiana. If you are an ancillary provider (DME, home infusion therapy, skilled nursing facility, home health, hospice, orthotics/prosthetics, dialysis, private duty nursing), your PNC is Elaine Williams. She can be reached at 312-653-4305 or ancillarynetworks@bcbsil.com. To find your Professional PNC, refer to this Illinois county map. PNCs for professional providers in Cook and DuPage Counties (Codes 16 and 22) are assigned by either Chicago ZIP code or city, as listed below. This information is also available in the Education and Reference Center section of our website at bcbsil.com/provider. ILLINOIS TERRITORY BREAKDOWN BY COUNTY CODE Northern (8, 43, 49, 81, 89 and 98) Gina Plescia Southern (2, 3, 12, 13, 14, 15, 17, 18, 24, 25, 26, 28, 30, 33, 35, 39, 40, 41, 44, 51, 60, 61, 64, 67, 73, 76, 77, 79, 80, 82, 83, 84, 87, 91, 93, 95, 96, 97 and 100) Teresa Trumbley West-Central (1, 5, 7, 9, 11, 29, 31, 34, 36, 42, 55, 59, 63, 65, 66, 68, 69, 75, 85, 86 and 94) Roy Pyers East-Central (10, 20, 21, 23, 27, 38, 53, 54, 57, 58, 70, 72, 74, 90, 92 and 102) Amanda Williams North Metro (4, 6, 19, 37, 45, 47, 48, 50, 52, 56, 62, 71, 78, 88 and 101) Cathy Dismuke South Metro (32, 46 and 99) Adam Kwiecien Northwest Indiana Kathleen Barry Cook County (16) See below for Cook and DuPage County Breakdown DuPage County (22) See below for Cook and DuPage County Breakdown COOK AND DUPAGE COUNTY BREAKDOWN BY CITY AND ZIP CODE Adam Kwiecien City: Lemont Ana Hernandez ZIP Codes: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60610, 60611, 60612, 60614, 60616, 60622, 60634 Cathy Dismuke Cities: Addison, Bartlett, Bloomingdale, Hanover Park, Hillisburg, Medinah, Roselle, Streamwood, Wayne Gina Plescia Cities: Arlington Heights, Elk Grove Village, Hoffman Estates, Schaumburg Kathleen Barry Cities: Aurora, Burr Ridge, Calumet City, Chicago Heights, Darien, Dolton, Flossmoor, Ford Heights, Glen Ellyn, Glendale Heights, Glenwood, Homewood, Lansing, Lisle, Lynwood, Matteson, Naperville, Olympia Fields, Park Forest, Richton Park, Riverdale, Sauk Village, South Holland, Steger, Summit, Thornton, Warrenville, Willowbrook, Woodridge Michelle Brownfield-Nance Cities: Calumet Park, Carol Stream, Country Club Hills, Countryside, Crestwood, Downers Grove, Harvey, Hazel Crest, Hickory Hills, Homer Glen, Markham, Midlothian, Oak Forest, Orland Hills, Orland Park, Palos Heights, Palos Hills, Palos Park, Posen, Robbins, Tinley Park, West Chicago, Wheaton, Willow Springs, Winfield, Worth Ramona Espino Cities: Bensenville, Clarendon Hills, Des Plaines, Elmhurst, Glencoe, Glenview, Golf, Hinsdale, Inverness, Itasca, Kenilworth, Lincolnwood, Lombard, Morton Grove, Mt. Prospect, Neenah, Niles, Northbrook, Northfield, Oak Brook, Oak Brook Terrace, Palatine, Prospect Heights, Rolling Meadows, Rosemont, Skokie, South Barrington, Villa Park, Westmont, Wheeling, Wilmette, Winnetka, Wood Dale Tyrone Sturgis City: Evanston; ZIP Codes: 60608, 60609, 60613, 60615, 60617, 60618, 60619, 60620, 60621, 60623, 60624, 60625, 60626, 60627, 60628, 60629, 60630, 60631, 60632, 60633, 60635, 60636, 60637, 60638, 60639, 60640, 60641, 60642, 60643, 60644, 60645, 60646, 60647, 60648, 60649, 60650, 60651, 60652, 60653, 60654, 60655, 60656, 60657, 60658, 60659, 60660, 60661, 60666, 60668, 60669, 60670, 60673, 60674, 60675, 60676, 60677, 60678, 60680, 60681, 60686, 60689, 60690, 60693, 60694, 60695, 60696 Vickey Jones Cities: Alsip, Bellwood, Berkeley, Berwyn, Blue Island, Bridgeview, Broadview, Brookfield, Burbank, Chicago Ridge, Cicero, Elmwood Park, Evergreen Park, Forest Park, Franklin Park, Harwood Heights, Hillside, Hines, Hometown, Indian Head Park, Justice, Knoxville, La Grange, La Grange Park, La Grange Highlands, Lyons, Maywood, Melrose Park, Merrionette Park, Norridge, North Riverside, Northlake, Oak Lawn, Oak Park, Park Ridge, River Forest, River Grove, Riverside, Schiller Park, Stone Park, Summit Argo, Westchester, Western Springs A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 4 VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
Code County 1 Adams 2 Alexander 3 Bond 4 Boone 5 Brown 6 Bureau 7 Calhoun 8 Carroll 9 Cass 10 Champaign 11 Christian 12 Clark 13 Clay 14 Clinton 15 Coles 16 Cook 17 Crawford 18 Cumberland 19 DeKalb 20 Dewitt 21 Douglas 22 DuPage 23 Edgar 24 Edwards 25 Effingham 26 Fayette 27 Ford 28 Franklin 29 Fulton 30 Gallatin 31 Greene 32 Grundy 33 Hamilton 34 Hancock 35 Hardin 36 Henderson 37 Henry 38 Iroquois 39 Jackson 40 Jasper 41 Jefferson 42 Jersey 43 JoDaviess Adam Kwiecien 312-653-1726 Amanda Williams 217-698-5179 Ana Hernandez 312-653-6488 Cathy Dismuke 312-653-2388 Gina Plescia 312-653-4733 Kathleen Barry 312-653-4247* Michelle Brownfield-Nance 312-653-4727 Ramona Espino 312-653-5032 Roy Pyers 217-698-2524 34 Teresa Trumbley 618-998-2528 1 Tyrone Sturgis 312-653-4208 Vickey Jones 312-653-6321 36 75 66 81 94 55 85 43 89 101 48 5 9 7 29 86 69 31 42 67 8 98 37 63 59 60 82 88 6 71 52 78 62 72 102 65 84 79 90 3 54 68 14 95 73 11 39 2 91 4 56 19 50 57 20 58 26 77 61 41 28 87 100 44 53 74 70 25 64 45 47 32 13 27 10 21 15 18 49 22 16 16 99 46 38 92 23 12 40 17 80 51 96 24 93 33 97 83 76 30 35 Code County 44 Johnson 45 Kane 46 Kankakee 47 Kendall 48 Knox 50 LaSalle 49 Lake 51 Lawrence 52 Lee 53 Livingston 54 Logan 58 Macon 59 Macoupin 60 Madison 61 Marion 62 Marshall 63 Mason 64 Massac 55 McDonough 56 McHenry 57 McLean 65 Menard 66 Mercer 67 Monroe 68 Montgomery 69 Morgan 70 Moultrie 71 Ogle 72 Peoria 73 Perry 74 Piatt 75 Pike 76 Pope 77 Pulaski 78 Putnam 79 Randolph 80 Richland 81 Rock Island 83 Saline 84 Sangamon 85 Schuyler 86 Scott 87 Shelby 82 St Clair 88 Stark 89 Stephenson 90 Tazewell 91 Union 92 Vermilion 93 Wabash 94 Warren 95 Washington 96 Wayne 97 White 98 Whiteside 99 Will 100 Williamson 101 Winnebago 102 Woodford Key: Cook County (16) and DuPage County (22) are split between Ana, Cathy, Gina, Kathleen, Michelle, Ramona, Tyrone and Vickey. City of Chicago is split between Ana and Tyrone. * NW Indiana is assigned to Kathleen. 02957.0414 JULY MARCH APRIL 2012 2014 2013 5
First Quarter 2014 Pharmacy Optimization Initiative Highlights BCBSIL would like to introduce a new feature on our Provider website. This year, at the end of each quarter, we will post a summary of recent pharmacy initiatives and program enhancements. These quarterly highlights will include helpful links to articles and related resources. Here is a quick preview of first quarter topics: Self-administered specialty drug claim processing reminder Checking your records for outdated drug codes Fourth quarter 2013 GuidedHealth program updates Electronic options for prescription drug benefit prior authorization requests Watch for the new Pharmacy Optimization Initiative 1st Quarter 2014 Highlights link on the Home page of our website at bcbsil.com/provider. GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL makes no endorsement, representations or warranties regarding GuidedHealth or any of its services or products. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly. PHARMACY PROGRAM UPDATES Pharmacy Program Changes Effective April 1, 2014 STANDARD FORMULARY CHANGES Based on the availability of new prescription medications and Prime National Pharmacy and Therapeutics Committee review of changes in the pharmaceuticals market, some revisions were made to the standard BCBSIL formulary effective April 1, 2014. Opsumit Valchlor Brand Medications Added to the Formulary, Effective April 1, 2014 Brand Medication Moved to a Higher Out-of-pocket Payment Level, Effective April 1, 2014 Non-Formulary Brand* Solaraze 1 This list is not inclusive. Other medications may be available in this drug class. STANDARD FORMULARY DISPENSING LIMIT CHANGES BCBSIL s standard prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on U.S. FDA-approved dosage regimens and product labeling. Effective April 1, 2014, dispensing limits were added/modified for the following drugs: Drug Class and Medication* Antibiotics Alinia tabs (nitazoxanide) Formulary Brand* Condition Used For Actinic Keratosis Zithromax tabs (azithromycin) Diabetes Invokana tabs (canagliflozin) Multiple Sclerosis Tecfidera Starter Kit (dimethyl fumarate) Tecfidera 120 mg caps (dimethyl fumarate) Generic Formulary Alternative(s) 1 fluorouracil cream, imiquimod cream Drug Class/Condition Used For Pulmonary Hypertension Topical Treatment of Cancer Dispensing Limit 6 tabs/30 days 60 tabs/180 days 30 tabs/30 days 60 caps/180 days 14 caps/180 days Formulary Brand Alternative(s) *, 1 Carac, Zyclara Targeted mailings were sent to members affected by formulary changes and dispensing limits per our usual process of notifying members prior to implementation of formulary changes that may be impacted. For the most up-to-date formulary and list of drug dispensing limits, visit the Pharmacy Programs section of our website at bcbsil.com/provider. *Third-party brand names are the property of their respective owners The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider. 6 VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER
Outpatient PPO Physical Medicine UM Program Updates and Helpful Hints As previously announced in the Blue Review, BCBSIL PPO Physical Medicine Utilization Management (UM) Program went into effect on Jan. 1, 2014. Please review the following updates to the PPO Physical Medicine UM Program: The City of Chicago group numbers included in the program at this time are as follows: P16705, P68263, P68267, P68265, P68268, P17600, P18600, P18601, P16628, P16642, P16643, P68266 and P68269. Group P20600 is not included in the program and services for this group should be preauthorized through Telligen. All occupational therapy services for City of Chicago PPO members will continue to be managed through Telligen. Central States Teamsters Adds New Members Effective March 1, 2014, Central States Teamsters (TEAMCARE), group number P13168, added approximately 5,000 new members. An additional 5,500 members transferred from 077316, 077317 and 077319 to P13168. Please ensure members present a current ID card so that claims are routed correctly. The following two reason codes have been introduced in conjunction with the PPO Physical Medicine UM Program: ORS: The claim has been denied. A clinical review to determine medical necessity is required. The claim will be reprocessed when medical records are received. No payment can be made at this time. ORC: Services determined not to be medically necessary, as defined under the plan. The claim is denied. Please be aware that at this time, the PPO Physical Medicine UM Program does not apply to facility providers. OrthoNet is not able to preauthorize services for the following provider types: Outpatient Rehabilitation Centers Hospital-based Rehabilitation Center Inpatient Setting Home Health Care (HHC) Agency Skilled Nursing Facility Emergency Room If you have questions regarding the status of your benefit preauthorization request, you may contact OrthoNet directly. OrthoNet Clinical Inquiries and Provider Services: 888-875-9480 Hours of Operation: Monday through Friday, 8:30 a.m. to 5:30 p.m. CST OrthoNet Website: orthonet-online.com If you have any questions, please contact your assigned BCBSIL Professional PNC. See pages 4-5 for details. OrthoNet is a registered trademark of OrthoNet LLC, an independent third party vendor that is solely responsible for its products and services. Please note that the fact that a guideline is available for any given treatment, or that a service has been preauthorized, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member s eligibility and the terms of the member s certificate of coverage applicable on the date services were rendered. Telligen is an independent third party vendor that is solely responsible for the products and services they offer. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions about the products or services they offer, you should contact the vendor(s) directly. Modifiers for Technical and Professional Components Modifiers 26 and TC: According to the CPT codebook, Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical component for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a physician or professional provider performs both the technical and professional service for a lab or radiological procedure, the provider must submit the total service on one line and bill it as global, rather than submitting each service individually. This material is for educational purposes only and is not intended to be a definitive guide for coding claims. Health care providers are instructed to submit claims using the most appropriate code based on the CPT codebook and other established industry standard guidelines and reference materials. MARCH APRIL 2014 2012 7
REVIEW FOR CONTRACTING INSTITUTIONAL AND PROFESSIONAL PROVIDERS PRSRT STD U.S. POSTAGE PAID PERMIT NO. 581 CHICAGO, IL Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 00014.0414 IN THE KNOW Claims Processing Update In previous issues of Blue Review, BCBSIL notified you that we will begin accepting partial batches, rejecting only individual claims that do not meet HIPAA compliance standards. Partial batches are a group of claims submitted where one or more claims may be rejected and all other claims will be processed. These enhancements will be effective in April 2014. When you transmit ANSI 5010 837 professional or institutional claim file(s), BCBSIL will forward all valid and successful claims for processing and adjudication. Our payer response reports will indicate which claims were rejected so that those claims may be corrected and resubmitted as appropriate. The entire batch of claims should not be resubmitted, as this will result in duplicate claims within the adjudication process. If you use a billing service or clearinghouse to submit claims on your behalf, please be sure they are aware of this information. If you have any questions about this notice, please contact our Electronic Commerce Center at 800-746-4614 for further assistance. Blue Review is a monthly newsletter published for institutional and professional providers contracting with Blue Cross and Blue Shield of Illinois. We encourage you to share the content of this newsletter with your staff. Blue Review is located on our website at bcbsil.com/provider. The editors and staff of Blue Review welcome letters to the editor. Address letters to: BLUE REVIEW Blue Cross and Blue Shield of Illinois 300 E. Randolph Street 24th Floor Chicago, Illinois 60601-5099 Email: bluereview@bcbsil.com Website: bcbsil.com/provider Publisher: Stephen Hamman, Vice President, Network Management Editor: Wes Chick, Divisional Vice President, Provider Relations Managing Editor: Jeanne Trumbo, Senior Manager, Provider Communications Editorial Staff: Margaret O Toole, Marsha Tallerico, Michael Chaney, Edna Johnson BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors mentioned in this newsletter. The vendors are solely responsible for the products or services offered by them. If you have any questions regarding any of the products or services mentioned in this periodical, you should contact the vendor directly. VISIT OUR WEBSITE AT BCBSIL.COM/PROVIDER