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An Independent Licensee of the Blue Cross and Blue Shield Association. 2010 All 2010 All Payers Payers Dec 17, 2010
An Independent Licensee of the Blue Cross and Blue Shield Association.
2010 All Payers2010 All Payers
Dec 17, 2010
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PresentersPresenters
• Cindy Garrison, CPC
• Denny Hartman, CPC
• Marie Burdiek
• Vicki Haverkamp
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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
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Institutional Relations Staff ChangesInstitutional Relations Staff Changes
Angie Strecker, Director Teresa VanBecelaere, Manger
Christie Blenden, Provider/Contract Consultant
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Misc UpdatesMisc Updates
• Health Information Technology (HIT)
• UB-04 (FL70)
• Limited Patient Waiver
• Medical Records Request
• Medical Policy Router
• Precerts
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Misc Updates - Health Information Misc Updates - Health Information Technology (HIT)Technology (HIT)
• New Web page
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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
a B c
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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
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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
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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
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New Medical Policy Web PageNew Medical Policy Web Page
Enterout-of-area three-digit
alphaprefix
EffectiveOct 1, 2010
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Misc Updates – Misc Updates – Pre-CertificationPre-Certification
• When Required
• Pre-certifications in Process
• Discharged
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Denny Hartman, CPCDenny Hartman, CPC
Provider Consultant
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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.
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Health Care ReformHealth Care Reform
• 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
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Health Care ReformHealth Care Reform
• 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
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Health Care ReformHealth Care Reform
• 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
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Health Care ReformHealth Care Reform
• 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
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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
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State of Kansas 2011 ChangesState of Kansas 2011 Changes
• 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
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State of Kansas 2011 ChangesState of Kansas 2011 Changes
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
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State of Kansas 2011 ChangesState of Kansas 2011 Changes
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.
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State of Kansas 2011 ChangesState of Kansas 2011 Changes
• 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):
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State of Kansas 2011 ChangesState of Kansas 2011 Changes
• 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
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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
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Federal Employee ProgramFederal Employee Program2011 Changes2011 Changes
• Uses CAP Blue Cross contracting provider contract as provider network
• ID cards use: 104 = Standard Option / Single
105 = Standard Option / Family
Standard Option
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Federal Employee ProgramFederal Employee Program2011 Changes2011 Changes
• 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
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Federal Employee ProgramFederal Employee Program2011 Changes2011 Changes
• 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
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Marie BurdiekMarie Burdiek
EDI Account Representative
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HIPAA 5010HIPAA 5010
•What is HIPAA 5010?
•Are you Ready?
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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.
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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
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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
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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
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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
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Claims Acknowledgement and Claims Acknowledgement and Reporting ChangesReporting Changes
• Reporting will change with 5010
• 999 will replace the 997
• 277CA (Claim Acknowledgement)
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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.
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HIPAA 5010 – ASK HIPAA 5010 – ASK TimelinesTimelines
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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
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How big is this change?How big is this change?
CODE SET COUNTS
14,000
3,800
72,00069,000
DIAGNOSIS PROCEDUREICD-9 ICD-10
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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.
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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?
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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.
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TURN OFF PAPER REMITTURN OFF PAPER REMIT
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TURN OFF PAPER REMITTURN OFF PAPER REMIT
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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
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Vicki Haverkamp, QueenVicki Haverkamp, Queen
Provider Consultant
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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.
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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
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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
MA18
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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
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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.
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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
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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
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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
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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.
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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.
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Policy and ProcedurePolicy and Procedure2011 Update2011 Update
• Letter July 26, 2010
• Minor Changes
