An independent licensee of the Blue Cross and Blue Shield Association

Provider Conferences –

2009Welcome and thank you for joining us –We’re glad that you are here!

2

Agenda

•

Updates and reminders•

Inter-Plan Programs Updates (BlueCard®

)•

Improving member’s health

•

Pharmacy and medication•

bcbsnc.com/providers/

•

Blue eSM

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Updates & reminders

4

National provider identifier (NPI)

•

Blue Cross and Blue Shield of North Carolina (BCBSNC) is compliant with the National Provider Identifier (NPI) mandate as required by the Health Information Portability and Accountability Act of 1996 (HIPAA).

•

Under HIPAA, providers and health insurance carriers are considered covered entities and were instructed to comply with the NPI mandate effective May 23, 2008. As a result, electronic transactions received by BCBSNC without an NPI will be rejected.

5

Member ID cards

•

We’ve redesigned our member ID cards, as part of an overall Blue Cross and Blue Shield Association effort to standardize ID cards for all Blue members nationwide.

•

The Association wants to ensure that the benefit information on the cards is consistent and easy to find and understand.

•

Additionally, a North Carolina senate bill, which became effective January 1, 2009, requires that all insurers list certain copayments

on ID cards, as well as, the effective

date of coverage or the issue date of the card.

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Member ID cards

Sample

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Print Verification of Coverage (VOC)

•

We’re adding to the My Member Services page on our Web site, tools that allow our members to download and print interim proof-of-coverage when awaiting a BCBSNC member ID card.

Manage Your Account

Request an ID card, change your contact information and more.

Benefits and Claims

View your claims, check your benefits, download forms and more.

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Provides minimum necessary member data for service eligibility

•Subscriber name and ID•Member names and IDs•Group number•Product•Effective date•In-network member *responsibility•Dental coverage indicator•Claims filing addresses•Customer service phone *number

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Member ID cards

Blue Medicare HMOSM and Blue Medicare PPOSM plans

BCBS Association symbols and BCBSNC text

Blue Medicare alpha-prefix:•YPWJ•YPFJ•YPJJ

Blue Medicare HMO or PPO designation

PARTNERS National Health Plans of North Carolina, Inc.

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Blue Medicare HMOSM

& Blue Medicare PPOSM

•

Only providers directly contracted with PARTNERS are considered as in-network for Blue Medicare HMOSM

and Blue Medicare PPOSM

.–

BCBSNC participating providers that are not contracted with PARTNERS can provide services to Blue Medicare PPOSM

members as part of the member’s PPO out-of-network benefits.–

Blue Medicare HMOSM

members have no out-of-network benefits (except for emergency care).

–

Claims submitted to BCBSNC for Blue Medicare HMO and PPO members in error will be returned to the submitting provider or electronic clearinghouse. This includes both paper and electronic claims.

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2009 Service area for Blue Medicare HMOSM

and Blue Medicare PPOSM

ALAMANCE CARTERET FORSYTH JOHNSTON ORANGE STANLY

ALEXANDER CASWELL GASTON LEE PERQUIMANS STOKES

ALLEGHANY CATAWBA GATES MARTIN PERSON SURRY

ASHE CHATHAM GREENE MECKLENBURG PITT WAKE

AVERY CUMBERLAND GUILFORD NASH RANDOLPH WATAUGA

BERTIE DAVIDSON HALIFAX NEW HANOVER RICHMOND WAYNE

BRUNSWICK DAVIE HERTFORD NORTHAMPTON ROCKINGHAM WILKES

CABARRUS DURHAM HOKE ONSLOW ROWAN YADKIN

CALDWELL EDGECOMBE IREDELL

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NCHC Changes

•

North Carolina Health Choice for Children (NCHC) members were issued new ID cards the last few weeks of 2008, which became effective January 1, 2009.

•

Claims for NCHC members previously processed on our Legacy claims system, are now being processed on our much newer Power MHS system (starting 01/01/09, for services provided on or after January 1).

13

BCBSNC Medicare Supplement and Medicare High Option programs

•

Effective January, 1, 2009, BCBSNC Medicare Supplement received a new name –

Blue Medicare

Supplement.

•

Also effective 01/01/09, processing of Blue Medicare Supplement and Medicare High Option claims transitioned from our Legacy claims system to the AMISYS claims processing system (for services provided on or after 01/01/09).

14

Credentialing and re-credentialing

•

On May 1, 2008, BCBSNC updated the minimum liability insurance requirements for initial credentialing and re-

credentialing of professional providers. •

The minimum insurance liability limits became one-million dollars per occurrence / three-million dollars aggregate (previously one-million dollars per occurrence / one-

million dollars aggregate). •

The limits increase went into effect May 1, 2008, for all new credentialing applications and became effective on May 1, 2009 for all re-credentialing applications.

15

Paper remittances –

going away

•

As part of BCBSNC’s

continuing efforts to become a “greener”

company for North Carolina, we’ve changed the

standard delivery method for provider payment details by discontinuing use of paper remittance as of April 19, 2009. Forms of discontinued paper remittance include:

–

Explanations of Payment (EOP)–

Notices of Payment (NOP)

–

EFT Paper Voided Checks & Payment Summary Pages (EFT information for providers enrolled for electronic funds

transfer)

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Sign-up for EFT online via Blue eSM

•

As of April 2009, providers have the ability to sign-up for electronic funds transfer (EFT) on-line with Blue eSM

. •

This new sign-up alternative makes it easier for providers to receive the fastest receipt of eligible payments for their BCBSNC claim submissions.

•

Once we have received and processed a claim, EFT payment is sent directly to the bank account of your designation.

–

Payments are sent through an automated clearing house and typically take up to two days to post, which is a much faster process than a conventional check cycle and our mailing to your bank to process and deposit.

17

Level I Provider Appeal

•

In August 2008 BCBSNC implemented a new provider appeal process, which replaced the post-service Provider Courtesy Review with a Level I Provider Appeal for billing disputes, medical necessity denials, and denials for no preauthorization of an inpatient stay.

•

This process allows providers to appeal without gaining consent from the member.

–

Pre-service Provider Courtesy Reviews handled by the Member Health Partnership Operations department did not changed.

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Level II Provider Appeal

•

Effective November 21, 2008, Physicians, Physician Groups, and Physician Organizations may file a Level II Post-Service Provider Appeal for medical necessity or billing disputes.

•

Level II Provider Appeals are conducted by an Independent Review Organization, and there is a filing fee associated with all requests for a Level II Post-Service Provider Appeal.

•

Requests for Level II Post-Service Provider Appeals must be submit in writing and received by BCBSNC within ninety (90) calendar days of the date of the Level I Post-Service Provider Appeal denial letter.

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Settlement Agreement

•

BCBSNC has previously communicated information related to the settlement agreement Love, et al. v. Blue Cross Blue Shield Association, et al., formerly Thomas, et al. v. Blue Cross Blue Shield Association, et al.

•

BCBSNC has made and is continuing to make enhancements to support greater transparency and operational efficiency.

•

For information about the Thomas/Love Settlement Agreement and what BCBSNC is doing to comply, access BCBSNC online at bcbsnc.com for public information or log in to Blue eSM

for secured information.

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Fee schedules available through Blue eSM

•

Beginning April 21, 2009, participating physicians with access to Blue eSM

will have the ability to view their fee schedule through a new transaction located in Blue eSM.

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Warehouse requisition no longer available

•

Due to a reduction in the forms offerings, BCBSNC eliminated the Provider Warehouse Requisition (B117 Form) in 2007.

•

The requisition form is no longer accepted by Moore Wallace and all copies in circulation should be destroyed.

•

Forms are available for copying from the Blue BookSM

Provider e-Manual, which is available on the BCBSNC Web site for providers.

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Inter-Plan Programs Updates (BlueCard®

)

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BlueCard®

claims processing enhancements

•

In November 2008 Inter-Plan Programs completed the transition of BlueCard®

host claims processing functions from the Legacy claims system to our Power MHS system. Using the Power-MHS system, we are now able to:

–

Improve data and financial claims accuracy through the use of a single pricing source

–

Increase claims processing speed through automation that replaced manual processes

–

Deliver pricing that meets with Thomas compliance

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BlueCard®

claims processing enhancements

•

Improvements with the Power MHS produced EOPs

for BlueCard®

claims include: –

Clearer descriptions on column headers–

Serial numbers assigned to claims print on the EOPs•

(Serial numbers of claims processed by BCBSNC, as the Host plan, begin with the number 310)

•

–

Enhanced remark codes with easy to understand descriptions –

Claim reversal information displays on the EOP

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BlueSquared®

(Blue2)

•

BlueSquared®

(Blue2) is a Web application that enables Blue Plans to view, send and track transactions related to the receipt of medical records in real time, as well as, access claims status and route appeals electronically to BlueCard®

member’s home plans. Performance enhancements through BlueSquared®

(Blue2):–

Improved exchange of informational messages, medical records and miscellaneous attachments for BlueCard®

claims–

Improved tracking of misrouted claims

–

Faster claim status inquiries for Inter-Plan claims

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PPA & radiology management services

•

BlueCard®

members from non-North Carolina BC and/or BS Plans are not included in the BCBSNC radiology management program administered through American Imaging Management (AIM). However, it’s important to always verify a member’s eligibility and prior authorization requirements, as a member may be enrolled in a benefit coverage plan that includes authorization prior to receiving certain radiological services.

•

To verify:–

Call the number on the member’s identification card–

Call 1-800-676-Blue–

Blue eSM

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Bundling rules

•

Just like other claims filed to BCBSNC, BlueCard®

claims should never be split billed or filed in partial increments:

–

Claims should be filed utilizing valid CPT and/or HCPCS codes

–

Claims are reviewed to determine eligibility for payment–

If services are considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, they are not eligible for separate reimbursement.

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COB collection form

•

All Blue

Plans have placed COB questionnaires on local Web sites, where they can be accessed, printed and presented to members believed to have COB.

•

Members believed to have other coverage should be given a copy of the questionnaire for completion.

•

Providers can download and print a copy of the COB questionnaire by accessing the Links section on Blue eSM

or on our Web site bcbsnc.com.

•

The mailing address for the member’s plan can be found on the back of their member ID card, or by calling the customer service number also listed on the back of the card.

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Medicare Advantage private fee for service

•

MA PFFS is a health plan offered by an organization that pays physicians and providers on a fee-for-service basis.

•

Patients can obtain services from any licensed physician or provider in the United States who is qualified to be paid by Medicare and accepts the health plan’s terms and conditions of payment.

•

There is usually no contract or network that providers sign up for to provide service to PFFS patients.

•

The Plan must provide the same coverage under PFFS as Medicare Part-A and Part-B, and may also offer additional benefits.

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Medicare Advantage private fee for service

•

Unlike coordinated care health plans, the MA PFFS plans are not required to contract with providers to participate.

•

Providers need to know that the member is covered under a PFFS health plan, accept the health plan’s terms and conditions and provide care to be able to bill for services.

•

PFFS plans call these providers “deemed providers.”•

If a provider does not agree to the terms and conditions, the provider should not provide services to the PFFS member (does not apply to emergency care situations).

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Medicare Advantage private fee for service

•

Ask the member for his or her ID card.

Members

will not have a standard Medicare card; instead, a Blue

logo will

be visible on the ID card along with the following logo:

•

Use the same processes you use today to verify eligibility by calling 1-800-676-Blue (2583) and providing the alpha prefix or electronically with Blue eSM

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Medicare Advantage private fee for service

•

Instructions for accessing PFFS terms and conditions are on the back of the member’s ID card.

•

Terms and conditions are posted on the Web site of the member’s Plan.

•

Terms and conditions for any Blue

MA PFFS product can also be accessed through BCBSNC’s

Web site at

bcbsnc.com/providers/edi/–

To view the terms and conditions for any MA PFFS member’s Blue health plan, from our Web site, enter the first three letters of the member’s identification number as listed on the member’s ID card and click “Go.”

Your browser will then be directed to the appropriate terms and conditions for that member.

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Medicare Advantage private fee for service

•

Submit claims to BCBSNC•

•

Do not bill Medicare directly for any services rendered to a MA member. Payment will be made directly by BCBSNC.

•

Reimbursements are the equivalent of the current Medicare payment amount for all covered services (i.e., the amount you would collect if the member was enrolled in original Medicare).

Details are provided in the product terms and conditions.

•

Providers can collect any applicable cost-sharing amount (i.e., co-pay, deductible).

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Improving member’s health

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Online member services

•

BCBSNC provides online services for members, including access to exclusive features designed to promote better health.

•

BCBSNC members can register or log in to our Member Services site bcbsnc.com/memberservices to access their account information or take part in programs designed to encourage healthy living and reward physical activity. Available member options include:

•Find a doctor•Get details of their health plan•Check claims 24/7

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Spanish speaking patients

bcbsnc.com/azul/

Spanish-speaking customer service1-877-258-3334

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Finding an interpreter

•

In North Carolina, providers can locate an interpreter to assist in communicating with Spanish-speaking and other foreign language-speaking patients through CATI (Carolina Association of Translators and Interpreters).

•

CATI is an association of working translators and interpreters in North Carolina & South Carolina and is a chapter of the American Translators Association.

•

CATI provides contact information of translators and interpreters within North Carolina at www.catiweb.org/index.htm.

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Universal Preventive Reminder

•

Customized services –

only if member is overdue for screening, per claims:

–

Colon cancer–

Breast cancer–

Cervical cancer–

Cholesterol–

Diabetes–

Pneumococcal

vaccine –

65+–

Vision screening –

65+

•

General services:–

Flu shot–

Blood pressure

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Provider Toolkits•

Preventive Health Topics:

−Adult Obesity−Childhood Obesity−Tobacco Cessation (including Spanish materials)−Stress Management

•

Screening Topics:−Chlamydia Screening−Colorectal Cancer Screening−Depression Screening−Mammography Screening

Toolkit contents include assessment tools, clinical guidelines, and patient education materials and worksheets.

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Results -

Toolkit volumesNumber of Toolkits Distributed by Year

From 2005-2008, Toolkit orders almost tripled!!

0

500

1000

1500

2000

2500

3000

3500

2005 2006 2007 2008

Toolkits

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Provider Toolkit Changes

•

Provider Satisfaction Survey indicated over half of providers were more likely to use the toolkit materials if they were offered online

•

Downloadable contents available online–

Patient education materials

•

Some items available for order–

Assessment tools, posters

www.bcbsnc.com/providers/toolkit

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Benefits for Nutrition Counseling

•

Nutrition counseling is a covered benefit for BCBSNC members.•

Nutrition counseling is available for both adults and children.•

Through nutrition counseling your patients can get help with weight loss, eating healthy and becoming more physically active.

•

The nutrition counseling benefit is available to commercial members (Blue Options and Blue Advantage) actively enrolled in our Member Health Partnerships (MHP) program.

•

Members can enroll in MHP by calling 1-800-218-5295.•

When members enroll in MHP, they receive up to six nutrition counseling visits per year with copays

waived if they go to a credentialed, licensed registered dietitian in an office-based setting.

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How to find a network dietitian

1. Enter zip code or county

2. Select “Nutrition”

in specialty field

3. Click on Find a Doctor Now

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Code Time spent with patient

99406 Intermediate visit 3-10 minutes

99407 Intensive visit 10 or more minutes

Since 2005, tobacco cessation counseling has more than quadrupled!

Tobacco Cessation Counseling Codes

•

Choice of code depends on time spent with the patient. These codes will be reimbursed in addition to other E & M services provided on the same day.

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Pharmacy and medication

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Medication Dedication / 90 days supply

•

Medication Dedication is the BCBSNC medication adherence program.

•

We are targeting the conditions of high blood pressure, high cholesterol, congestive heart failure and diabetes. Our goal is to improve member health through improved medication adherence.

•

Providers are encouraged to write 90 day scripts whenever possible.

•

Program includes generic copay

waiver through 12/31/09,

for drugs used to treat the four targeted conditions.

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Drugs being added to Prior Review list as of July 1, 2009•

Effective July 1, 2009, prior review is required for coverage of

alefacept

injection (Amevive) and for transmucosal

fentanyl

(Actiq, Fentora).

•

In order to request coverage for Amevive

or for transmucosal

fentanyl, providers must complete and fax the appropriate prior review fax

form that can be downloaded from our Web site at bcbsnc.com.

•

Criteria for coverage of Amevive

are outlined in a new medical policy that is available online in the “Medical Policy”

section.•

The criteria for coverage of transmucosal

fentanyl

follows FDA-

approved indications.

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Self administered medications

•

BCBSNC’s

pharmacy and medical staff reviews all medications on a periodic basis to determine if any medications can be safely administered by a member as self administered.

•

When safe for self administration, medications are covered under the member’s pharmacy benefit rather than the member’s medical benefit.

•

As of January 1, 2009, thirty-nine additional drugs have been added to the list of self administered medications.

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Reclassified as self administered effective January 1, 2009•

Injectables

–

Antagon

–

Apokyn

–

Bravelle

–

Chorionic

Gonadotropin

–

Cetrotide

–

Cimzia

–

Follistim/AQ –

Fuzeon

–

Ganirelix

–

Gonal

–

Luveris

–

Menopur

–

Novarel

–

Ovidrel

–

Pregnyl

–

Repronex

–

Somatuline

–

Zorbtive

•

Oral–

Copegus

–

Exjade

–

Gleevec

–

Kuvan

–

Nexavar

–

Orfadin

–

Rebetol

–

Revlimid

–

Ribasphere

–

Ribavirin

–

Sensipar

–

Sprycel

–

Sutent

–

Tarceva

–

Temodar

–

Thalomid

–

Tykerb

–

Xeloda

150mg –

Xeloda

500mg

•

Inhaled–

Tobi

–

Pulmozyme

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•

Electronic prescribing (ePrescribing) is an efficient, economical and secure way of using health care technology (e.g., computers or personal digital assistants) to improve prescription accuracy and patient safety, while increasing the use of more cost effective drugs by providing patient specific drug information at the point of care.

–

ePrescribers

electronically and securely incorporate patient medical information with health plan formulary, patient eligibility and medication history at the point of care.

–

–

The result is a safe and efficient process with more accurate medication orders being electronically sent to the patient’s pharmacy of choice.

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•

Time and safety advantages:–

Streamline provider prescribing process–

Clearer prescriptions with fewer calls and faxes to and from pharmacies asking for clarification on written scripts

–

Ability to automate prescription refill authorizations–

Improve patient safety. ePrescribe

will detect drug-drug interaction and provide information back to providers immediately

–

Point of care access to patient medication history–

More time to devote to patient care

bcbsnc.com/providers/eprescribe

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eDispenseTM

•

eDispenseTM

Part-D Vaccine Manager, a product of Dispensing Solutions, Inc., (DSI) makes available through it’s secure online access, real-time claims processing for in-office administered Medicare Part-D vaccines.

•

Services offered with eDispenseTM

allow providers to verify member’s Medicare Part-D vaccination coverage and submit claims quickly/electronically –

to our pharmacy

benefits manager medco®

–

accessed directly from providers in-office Internet connection.

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eDispenseTM

•

eDispenseTM

offers providers the ability to:–Verify members’

Medicare Part-D vaccination eligibility and

benefits in real-time–Advise members of their appropriate out-of-pocket expense

for Medicare Part-D vaccines–Submit Medicare Part-D vaccine claims electronically to

medco®

54

eDispenseTM

•

Signing up for eDispenseTM

is easy, just go to Dispensing Solutions’

Web site and complete a simple one-time

online enrollment application at enroll.edispense.com.•

You will need your:–Tax identification number–National provider identifier (NPI)–Medicare ID number–Drug enforcement administration (DEA) number–State medical license number

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eDispenseTM

•

Providers can contact Dispensing Solutions for assistance with enrollment and claims by calling their customers support center at 1-866-522-EDVM (3386).

•

Because medco®

is the Medicare Part-D pharmacy benefits manager for Blue Medicare HMOSM

& Blue Medicare PPOSM

products and BCBSNC products, eDispenseTM

can be used for Part-D electronic transactions for both BCBSNC and PARTNERS Medicare Part-D eligible vaccine claims.

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bcbsnc.com/providers/

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Online resources – bcbsnc.com/providers/

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BCBSNC formulary information

•

The most up-to-date formulary information for BCBSNC commercial plans can be found on the “Prescription Drug Search”

located on our Web site at bcbsnc.com.

–

Just type in the name of the drug you are looking for, and you will find information on that drug’s tier value, generic availability, average ingredient cost and other important information.

–

To compare tier and average cost information between drugs in the same or similar therapeutic class, click on “Review Options.”

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Prior Review

•

The prior review list is maintained and available on the BCBSNC Web site at bcbsnc.com/providers/ppa.

•

The prior review list is considered as “notice of a change.” It is important to check the list quarterly.

•

•

It is simple to use, just enter in the code that you need to know about and click the Search button. If the code is available for review, it will be highlighted within the text.

•

•

BCBSNC updates the list in advance to allow 90 days notice for existing codes.

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Updates to medical policies available online

•

BCBSNC Medical Policies consist of medical guidelines, including diagnostic imaging management policies, payment guidelines and evidence-based guidelines.

•

Medical guidelines are based on constantly changing medical sciences. Therefore, policies are periodically updated and reviewed.

•

The updates to medical policies are available online at bcbsnc.com/providers/medicalpolicy/updates.

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Please continue to the next link to see Blue eSM game show questions and answers presented in the general session