Blue Cross & Blue Shield of Kansas

2012

Denny Hartman, CPCBCBSKS Provider Representative,Hospitals in Southern KS

Connie WinkleyBCBSKS Institutional RelationsEducation/Communication Coordinator

Cindy Garrison, CPCBCBSKS Provider Representative,Hospitals in Northern KS

Marie BurdiekElectronic Data Interchange (EDI)Account Representative

Presented by:Presented by:

AgendaAgendaConnecting with Providers

Other Party Liability (OPL)

Quality Based Reimbursement Program (QBRP)

Electronic Data Interchange (EDI)

Connected to our Connected to our ProvidersProvidersInstitutional Provider Representative

Training

eNews

BCBSKS Website (www.bcbsks.com)

Blue Access

Connected to our Connected to our ProvidersProvidersAvaility

Webinars

KHA Convention

All Payers Workshop

BCBSKS Contact Information on the Web

Other Party Liability (OPL)Other Party Liability (OPL)Focus on Cost Containment by

coordinating payments between carriers

Non-Duplication of Benefits Provision

Exclusions

Other Party Liability (OPL)Other Party Liability (OPL)Duplicate Coverage

Maintenance of Benefits (MOB)

Accidents

Worker's Compensation

Auto No-Fault

The OPL Web Questionnaire

OPL - OPL - Patient Information FormPatient Information Form

Submit OPL Information Submit OPL Information Electronically Electronically

Other Party LiabilityOther Party LiabilityThe Remittance Advice (RA) for secondary

payers:◦Shows total amount paid by primary carrier

◦Shows total amount of patient responsibility

◦Shows the total provider write-off

◦Eliminates the need to retrieve the primary carrier EOB

Other Party LiabilityOther Party Liability To identify an OPL claim on the RA the CNTR

column will state OP. The OPL Adjustment Reason Code (ARC) and Remarks on the RA for OPL claims are listed in the table below with the code defined.

ARC Remarks Code Definition19 MA04 This service is due to a job-related illness or injury covered

by Worker's Compensation21 MA04 The services are Motor Vehicle relate22 MA04 The Primary Carrier must process first and an Explanation

of Benefits from the Primary Carrier is required.

22 N48 The Explanation of Benefits (EOB) from the Primary Carrier does not match this claim.

23 Paid as secondary carrier23 MA04 The patient has accepted a financial settlement from

another insurance company for this claim.23 M43 The Primary Carrier's payment exceeds the amount

payable under the patient's contract. No Secondary Carrier payment is available on this claim.

227 N179 Awaiting a response to an OPL Questionnaire sent to the patient.

Explanation of BenefitsExplanation of BenefitsCOB: Duplicate coverage

secondary payment formula

Provider's Contractual Obligation

Worker's Compensation

Quality Based Reimbursement Quality Based Reimbursement ProgramProgram (QBRP) (QBRP)

Background◦Patient Protection and Affordable

Care Act

◦Reimbursement arrangement that incentivizes quality

◦Requirement for a health plan to be eligible to participate on the Exchange

Exchange Timeline◦2014◦BCBSKS quality incentive programs

will be evaluated for approval in 2013.

QBRP Criteria for 2013◦Collaborative effort to develop our

QBRP◦The goal: provider's quality, safety

and affordability continually improve

Quality Based Reimbursement Quality Based Reimbursement Program Program (QBRP)(QBRP)

Quality Measures◦3 Prerequisites

1. File claims electronically2. Accept electronic remittance advices

through the ANS1835 transaction or retrieve remittance advices from the BCBSKS website.

3. Use the BCBSKS electronic portal for inpatient hospital precertification and continued stay reviews.

Quality Based Reimbursement Quality Based Reimbursement ProgramProgram (QBRP) (QBRP)

7 Quality Measures◦ 3 measures require a signed attestation

form only and 4 measures require reporting.

◦ Process oriented vs. outcome based

◦ Incentive payment is not based on the scores submitted.

Quality Based Reimbursement Quality Based Reimbursement ProgramProgram (QBRP) (QBRP)

Timeline◦ A one-time attestation form and

information required for quality measures were due December 1, 2012.

◦ Updated information must be received no later than May 15, 2013.

◦ Failure to report information by May 15, 2013 will result in the reduction of the incentive previously given.

Quality Based Reimbursement Quality Based Reimbursement ProgramProgram (QBRP) (QBRP)

TriWestTriWestTransition

FAQs

Web Services

2012 BCBSKS All Payers Workshop