2010 All Payers

transcript

An Independent Licensee of the Blue Cross and Blue Shield Association.

2010 All Payers2010 All Payers

Dec 17, 2010

PresentersPresenters

• Cindy Garrison, CPC

• Denny Hartman, CPC

• Marie Burdiek

• Vicki Haverkamp

AgendaAgenda

Vicki Haverkamp

•Medical Policies

•National Consumer Cost Tool

•TRICARE

Cindy Garrison

•Staff changes

•Misc Updates

Denny Hartman

•Healthcare Reform

•State of Kansas 2011 Changes

•FEP 2011 Changes

Marie Burdiek

•HIPAA

•Electronic Claims

•Electronic RA

Institutional Relations Staff ChangesInstitutional Relations Staff Changes

Angie Strecker, Director Teresa VanBecelaere, Manger

Christie Blenden, Provider/Contract Consultant

Misc UpdatesMisc Updates

• Health Information Technology (HIT)

• UB-04 (FL70)

• Limited Patient Waiver

• Medical Records Request

• Medical Policy Router

• Precerts

Misc Updates - Health Information Misc Updates - Health Information Technology (HIT)Technology (HIT)

• New Web page

Enter the appropriate diagnosis code describing the patient's reason

for the visit at the time of the outpatient encounter.

Misc Updates – UB-04 – Misc Updates – UB-04 – Patient Reason for VisitPatient Reason for Visit

• Effective Jan 1, 2012

Required for ALL outpatient claims

• Claim submission

Electronic – loop "2300 HI"

Paper – form locator 70

• Be sure your vendors are aware

Start working with them NOW

70 PATIENT REASON DX

Misc Updates – Misc Updates – Limited Patient WaiverLimited Patient Waiver

• New waiver

• Limited Patient Waiver (LPW)

• Notice of Personal Financial Obligation (NOPFO) Discontinue effective Jan 1, 2012

• Available on the Web at http://www.bcbsks.com/CustomerService/Providers/forms.htm

Misc Updates – Misc Updates – Medical Records RequestMedical Records Request

• Facility responsible for obtaining records Hospital's

Physician's

• Will only ask for records once

• If you question the processing, you can Call customer service

Do a written inquiry within 120 days of RA

Do a written appeal within 180 days of RA

Misc Updates – Misc Updates – Medical Policy RouterMedical Policy Router

• Gives providers the ability to self-service

• Eliminate some phone calls

• Increase transparency

• Potentially prevent some claim issues or claim denials due to medical policy

New Medical Policy Web PageNew Medical Policy Web Page

Enterout-of-area three-digit

alphaprefix

EffectiveOct 1, 2010

Misc Updates – Misc Updates – Pre-CertificationPre-Certification

• When Required

• Pre-certifications in Process

• Discharged

Denny Hartman, CPCDenny Hartman, CPC

Provider Consultant

Health Care ReformHealth Care Reform

• Check out the BCBSKS Web site – www.bcbsks.com FAQs are available on our Web site regarding "Dependent

to Age 26" and "Grandfathered Plans," as well as other topics.

Details about continuing legislative health care changes and their affect on coverage.

• Sign up to receive Health Care Reform Updates via e-mail.

• Patient Protection and Affordable Care Act (PPACA)

Blue Cross Newsletter, Nov 19, 2010 (BC-10-16)

Website for a complete listing of preventive services:

www.healthcare.gov/law/about/provisions/services/lists.html

Preventive Health Benefits

• Grandfathered Health Plans PPACA does not require 100% of preventive benefits,

however, must comply with some of the requirements

• Non-grandfathered Health Plans Health plans must provide PPACA's recommended Preventive

Health services without cost share to the insured

All deductibles, coinsurance or co-payments are waived and the health plan is to pay 100% of the plan allowance to the BCBSKS contracting provider

Health Plans

• Can be outpatient setting

• Use CPT description of preventive services when choosing CPT code

• Annual exam for members 3 years and older allowed per benefit period with no cost sharing

Annual Wellness / Preventive Services

• Diagnosis code is very important!

• Quick reference guide on bcbsks.com (newsletter)

• If not Well Person ICD-9 codes, then it is cost shared!

• Diagnosis codes drive cost sharing and in some cases, actual coverage!

Coding for Preventive Health Benefits

State of Kansas 2011 ChangesState of Kansas 2011 Changes

Patient Protection and Affordable Care Act (PPACA)

• Non-grandfathered – Will not be exempt from PPACA's provisions

• Preventive care provided

• Coverage for children up to age 26

• SOK offers PSA's, unlimited mammograms, and colonoscopies regardless of diagnosis as long as member uses contracting provider

• Must be pre-approved

• May include Applied Behavioral Therapy, Development Speech Therapy, Development Occupational Therapy Developmental Physical Therapy

• Periodic re-evaluations and assessments required

• Continued improvement must be shown

• Call New Directions for prior approval

Autism Services

Intravenous & Injectable Anti-cancer Drug Rider

Separate coinsurance and coinsurance maximum

Medical deductible & coinsurance does not apply

25% coinsurance to maximum of $750 per member / per year

After $750 max is met, coverage is 100% rest of year

Non-network provider – Same benefits and member pays amount over the MAP

General Information

Return requested information within one (1) year and 90 days from the date of service. If request is close to the end of this time period, you have 90 days from date request for more information is made. If not received within 90 days, claim will be denied.

Adjustments of claims – Requests must be received within one 1) year and 90 days from the date of service. After 1 year and 90 days from date service, only claims that require adjustments due to legal finding or audit will be adjusted if the request is received within 180 days of the completion of that finding. Fraudulent billing has no time limits.

• Blood, Blood Products, Blood Storage

• Surgical treatment or other related services for surgical treatment of obesity

• Sleep studies provided within the home

• Supplies and prescription products for tobacco cessation programs and treatment of nicotine addiction.

Exclusions (not a complete list):

• Covers the Medicare Part A & B deductible and coinsurance

• The 1st three pints of blood are covered

• Hospice care is available effective January 1, 2011.

• There is no coverage for charges in excess of Medicare's approved amounts

• Skilled nursing – The Member must meet Medicare's requirements

Kansas Senior Choice Plan C Summary

Federal Employee ProgramFederal Employee Program2011 Changes2011 Changes

• Non-grandfathered under Patient Protection and Affordable Care Act (PPACA)

• Preventive care with no cost sharing for members when performed by a Preferred Provider

• Coverage for children up to age 26

Basic or Standard Option

• Uses CAP Blue Cross contracting provider contract as provider network

• ID cards use: 104 = Standard Option / Single

105 = Standard Option / Family

Standard Option

• Uses the Blue Choice provider network except for emergency care

• NO BENEFITS are available for service provided by institutional providers who are not part of Blue Choice provider network

• Non-hospital institutional providers who are in the CAP provider network are considered to be Blue Choice providers

• ID cards will have the work "BASIC" written on outline of the United States and the following:

111 = Basic Option / Single

112 = Basic Option / Family

Basic Option

• Prior approval required for out-patient surgery for morbid obesity

• Prior approval required for all out-patient IMRT services except IMRT related to the treatment of head, neck, breast or prostate cancer.

• Prior approval is required for IMRT of brain cancer

• Pre-certification is required for partial day, home health, hospice, in-patient skilled nursing facilities and in-patient services

Miscellaneous

Marie BurdiekMarie Burdiek

EDI Account Representative

HIPAA 5010HIPAA 5010

•What is HIPAA 5010?

•Are you Ready?

HIPAA HistoryHIPAA History

•Current version is 4010A1

•New version is 5010

•5010 applies to all electronic healthcare transactions

Health Insurance Portability and Accountability Act requires

certain standards for electronic healthcare transactions.

Covered EntityCovered Entity

• All covered entities who exchange information electronically must do so in the HIPAA 5010 format.

• Covered entities include: Health Plans/Payers

Health Care Clearinghouses

Health Care Providers – any provider of medical or other health services, or supplies, who transmits health information electronically

Industry TimelinesIndustry Timelines

•December 31, 2010

• January 1, 2011

• January 1, 2012 What happens Jan. 1, 2012 ?

Only version HIPAA 5010 will be accepted

Industry is not expecting any extensions to these dates

Enhancements with 5010Enhancements with 5010

Improvements are made in technical, structural and data content

• It is more specific in what data needs to be collected and transmitted

• Accommodates reporting of clinical data (e.g., ICD-10 diagnosis and procedure codes effective October 1, 2013)

• Distinguishes the difference between a principal, and admitting diagnosis codes

• Increases the number of diagnosis codes that can be reported

Examples of ChangesExamples of Changes

• Billing and service facility ZIP codes are now expanded to the ZIP + 4

• Billing provider segments must contain the physical address not a P.O. Box

• The 835 transaction will only return the first 20 characters of the patient account number

• Preferred Health Professionals (PHP) Payer ID 00023 will be replaced by 31478

Claims Acknowledgement and Claims Acknowledgement and Reporting ChangesReporting Changes

• Reporting will change with 5010

• 999 will replace the 997

• 277CA (Claim Acknowledgement)

5010 Enrollment 5010 Enrollment ProceduresProcedures

•Active Trading Partners will not have to complete enrollment forms for 5010.

•Vendors will determine test or production status.

•PC-ACE Pro32 users will not have to test.

•EDI will rely on email as the primary means to contact trading partners regarding 5010 setup.

HIPAA 5010 – ASK HIPAA 5010 – ASK TimelinesTimelines

Changing to ICD-10Changing to ICD-10

• US Standard on 10/01/2013

• No phase in period

• ICD-10 is date driven by date of service

ICD-9 will continue until all services prior to 10/01/2013 are through the system.

ICD-10 is the only coding valid on claims with date of service 10/01/2013

www.cms.gov/ICD10

How big is this change?How big is this change?

CODE SET COUNTS

14,000

72,00069,000

DIAGNOSIS PROCEDUREICD-9 ICD-10

HIPAA 5010 Sets the Stage for HIPAA 5010 Sets the Stage for ICD-10ICD-10

• ICD-10 cannot be implemented until the transition to 5010 is complete!

•Extension was previously granted.

•No additional extensions.

Questions to Ask Your Questions to Ask Your Vendor, Billing Service or Vendor, Billing Service or ClearinghouseClearinghouse

1. Will software upgrades or changes accommodate both HIPAA 5010 and ICD-10?

2. What if any costs are involved?

3. When will the upgrades or changes be available for implementation?

4. Will I be required to test with ASK?

5. Will my software support and convert the 277CA into a readable format?

6. What customer support and training is provided?

7. How will the software changes handle both ICD-9 and ICD-10 before and after the deadline for code sets?

HIPAA 5010 - Next StepsHIPAA 5010 - Next Steps

What should I do?

• Contact vendor

Ask for dates of activities, upgrade deployment and transitions

• Contact clearinghouse

Ask if they have been in touch with your payers

Ask for dates for activities and transitions

• Self educate

Frequently review payer Web sites for HIPAA 5010 information.

Sign up for e-mail notification.

TURN OFF PAPER REMITTURN OFF PAPER REMIT

BCBSKS Internet Log In BCBSKS Internet Log In IssuesIssues

Contact BCBSKS Customer Service

1-800-432-3990

• Please have user name

• NPI number

• Answers to your challenge questions

Vicki Haverkamp, QueenVicki Haverkamp, Queen

Provider Consultant

BCBSKS Secondary to BCBSKS Secondary to Medicare (MSP) Medicare (MSP)

While our expectation is to receive secondary claims to

Medicare via the cross over system, this does not always happen.

MSPMSP

Some of the reasons the claim does not cross over could be:

o We do not have the patient loaded as Medicare primary

o We have the wrong Medicare information loaded (i.e. ID, name, effective date, etc.)

o Third-party claims

o Negative amounts

MSPMSP

• Providers should contact customer service (1-800-432-3990) or their provider consultant if the Medicare remittance advice indicates the claim did not crossover to BCBSKS (no MA18) for help in determining why a claim was not received.

Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them

MSP – Electronic ClaimMSP – Electronic Claim

• Submit all the Medicare processing information.

Total amount billed

Medicarepayment

ProviderWrite-off

Deductible &coinsurance

Non coveredamounts when

applicable

Call ASK at 1-800-472-6481

National Consumer Cost Tool National Consumer Cost Tool

New effective Jan. 1, 2011

The purpose is to enable members to obtain information on estimated costs

for common health care services.

Not available to BCBSKS members at this time.

NCCTNCCT

• Members will access through their Plan's Web site.

• The member will enter their member Identification number,

• Select the treatment category, and

• Select the geographic area desired for service.

• Members can choose from 54 of the most common, elective procedures for inpatient, outpatient and diagnostic services.

How it works

NCCTNCCT

• The estimates are developed using twelve months of claims data from contracting facilities.

• Medicare and secondary claims are excluded.

• For the inpatient treatment, categories episodes are built by summing all claims created at the

facility from admission to discharge.

• Outpatient episodes sum all claims created on that day of service at that facility and also

may include ‘pre-work’ diagnostics done beforehand.

• Cost estimates are updated approximately every six months.

Pricing

NCCTNCCT

• The approximate costs for the selected treatment category,

• for hospital/facility-based services,

• the approximate costs with the name and practice location of the hospital/facility,

• the approximate out of pocket liability calculated by the member’s Plan, and

• links to supplemental information such as health/wellness, care management, quality, etc.

Information Exhibited

Off Site ServicesOff Site Services

Services provided off-site of the physical presence of the main hospital campus must be billed on the

CMS-1500 claim form, except in those cases where that off-site location is the sole place of service

for an outpatient ancillary service or as determined by BCBSKS. When hospitals provide multiple services off-site of the main hospital campus,

an addendum agreement to peer group pricing may be offered.

Off Site Services Off Site Services (cont)(cont)

• Submit on a CMS 1500

• Reimbursement will be based on

the Blue Shield fee schedules and

Blue Shield guidelines will be applicable.

Policy and ProcedurePolicy and Procedure2011 Update2011 Update

• Letter July 26, 2010

• Minor Changes

2010 All Payers

Documents