Blue Cross and Blue Shield of Kansas
2014 Hospital Quadrant Meeting
www.bcbsks.com
www.availity.com
Today's Presenters
• Sally Stevens
Provider Representative for Southern Kansas,
Institutional Relations, BCBSKS
•
Cindy Garrison, CPC
Provider Representative for Northern Kansas,
Institutional Relations, BCBSKS
•
Connie Winkley
Education Coordinator, Institutional Relations,
Blue Cross and Blue Shield of Kansas
•
Marie Burdiek
Account Representative, Electronic Data Interchange (EDI),
Blue Cross and Blue Shield of Kansas
www.bcbsks.com
www.availity.com
Today's Agenda

Introduction

Medicare Advantage billing guidelines for other Blue Plans

Present on Admission (POA) Indicator
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BlueCard

Inpatient Electronic Precertification

Other Party Liability (OPL)

2015 Policies & Procedures

Quality-Based Reimbursement Program (QBRP)

Electronic Data Interchange (EDI)
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www.bcbsks.com
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Q&A
MEDICARE ADVANTAGE
• Medicare Advantage (MA) facilitates the coordination of
Blue Plan Medicare Advantage claims and services for
members and providers.
• MA products must cover the same services as original
Medicare Part A/B and may include additional benefits.
• MA has expanded to allow Plans to offer several types of
MA products.
CMS Employer Group Waiver Guidance
• Allows MA PPO and HMO groups to enroll members in areas
where provider networks do not exist.
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MEDICARE ADVANTAGE
MA Private Fee-for-Service (MA PFFS)
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Member may receive services from any Medicare provider
that accepts the Home Plan's terms and conditions.
Identifying a MA member:
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MEDICARE ADVANTAGE
MA Claims Submission
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Submit all Medicare Advantage claims to BCBSKS
Do not bill Medicare directly for any services rendered to a
Medicare Advantage member
• Payment will be made directly by a Blue Plan
• A provider's contracting status with the Centers for
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Medicare & Medicaid Services (CMS) determines MA
payment allowances
MA claims cannot and will not be processed pursuant to
BCBSKS Policies and Procedures
Member's Plan is solely responsible for determining pricing
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MEDICARE ADVANTAGE
MA Claims Submission
Home Plans need the following to adjudicate MA claims accurately and timely:
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National Provider Identifier (NPI)
Source of Referral for Admission (one alpha-numeric character indicating transfer or
admission)
Core Based Statistical Area
Treatment Authorization Code
Admitting Diagnosis Code
Height and Weight for End-Stage Renal Disease (ESRD) patients
Ambulance Pick-Up Zip Code
HIPPS Code for Home Health, Skilled Nursing and Inpatient Rehabilitation
Taxonomy Code (if the provider represents an institutional with more than one
subpart to bill)
Certified Registered Nurse Anesthetists (CRNA) Special Code
Provider Service Location ZIP Code, if different than the billing ZIP Code
Present On Admission (POA) Indicator
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MEDICARE ADVANTAGE
MA Appeals
• Reason for appeal may include:
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A delay in providing, arranging for or approving healthcare services
The amount a member must pay for a service
Appeals can be submitted by
 Member
 Provider
 Assignee or the member's legal representative
Appeals submission:
 Submit to BCBSKS
 BCBSKS forwards to member's plan within 3 days of receipt
 Member's MA Plan will respond to provider within 30 days
Member's plan determines medical policy
Provider agrees to abide by final determination
Obtain appeals policies and procedures from the MA Plans
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PRESENT ON ADMISSION (POA)
• Mandated in 2005 that providers report POA indicators for all diagnoses
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submitted on Medicare inpatient acute care claims effective October 1, 2007
POA is the condition(s) present at the time the order for inpatient admission occurs.
Differentiates condition(s) present at time of admission from those that
develops during the admission.
Providers must report one of five indicators:
 Y = yes (present at the time of inpatient admission)
 N = no (not present at the time of inpatient admission)
 U = unknown (documentation is insufficient to determine if condition was
present at the time of admission)
 W = clinically undetermined (provider is unable to clinically determine
whether condition was present on admission)
 Blank (electronic claims) or 1 (paper claims) = exempt from POA reporting
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PRESENT ON ADMISSION (POA)
Present On Admission FAQs
Q – When is POA data required on BCBSKS claims?
A – POA reporting requirements applies to inpatient claims where MS-DRG assignment is required to determine
payment. Includes swing-bed and skilled nursing facilities claims and rehabilitation and psychiatric units.
Q – Does POA reporting apply to outpatient or ambulatory surgery services?
A – No, this program is only for inpatient acute care admission.
Q – What facilities are exempt from the POA reporting?
A. – When Medicare primary facilities do not need to report POA on the BCBS secondary claim.
Q – When reporting a POA indicator for exempt diagnosis codes, do I use a "blank" or a 1?
A – For electronic claim submission no indicator is required. Leave the position "blank". For paper
claims, BCBSKS prefers reporting a "1" verse leaving an exempt code blank.
Q – If the POA indicator is not on the claim, will the claim be returned?
A – Yes, the claim will be returned to the hospital for correct submission of the POA information.
Q – Are Skilled Nursing Facilities and swing beds exempt from billing with the POA indicator?
A – No. POA reporting is required for SNF and swing-bed units.
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BlueCard Program
The BlueCard Program:
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Enables a member of one Blue Plan to obtain services while traveling or residing in
another Blue Plan's service area.
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Allows providers to submit claims for patients from one Blue Plan (domestic and
international) to the local Blue Plans.
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BCBSKS is your one point of contact for all BlueCard claim-related issues.
Exempt from the BlueCard Program:
• Stand-alone dental
• Prescription drugs
• The Federal Employee Program (FEP)
www.bcbsks.com
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BlueCard Program
BlueCard ID Number:
• The
majority of Blue-branded ID cards display a three character
alpha prefix in the first three positions of the subscriber's ID
number.
• Alpha prefix is necessary for inquiries and proper claims filing.
• A Blue member ID number includes the alpha prefix in the first
three positions and all following characters (between 6 and 14
numbers/letters) for a total of 17 characters.
www.bcbsks.com
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BlueCard Program
BlueCard Suitcase Logos:
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Blank (empty) Suitcase
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PPO in a Suitcase
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No Suitcase
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Limited Benefits Product ID Cards include one or more of the following:
 Product names
 Green stripe at the bottom of the card
 Limited benefits product statement on the front or back of the ID card
 Black cross and/or shield to differentiate it from other ID cards
www.bcbsks.com
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BlueCard Program
Coverage and Eligibility Verification:
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Eligibility and benefits for out-of-area members can be verified through the Availity
Web Portal or by using real time transactions through your clearinghouse.
For additional information on out-of-area members, contact BlueCard at 1-800-676BLUE (2583)
Utilization Review:
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Always verify benefits with the member's Blue Plan prior to providing services.
Eligibility and benefits for out-of-area members can be verified through the Availity
Web Portal or by using real time transactions through your clearinghouse.
Claims Filing:
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Always submit BlueCard claims to BCBSKS
Always include entire member ID #
Do not send duplicate claims. Visit the Availity Web Portal to check claim status.
www.bcbsks.com
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BlueCard Program
Medical Records Request:
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The request for records will be sent to contracting providers by BCBSKS.
Non-contracting providers could receive record requests from either BCBSKS or the
plan where the member is enrolled.
The request will clearly indicated what records are needed and where the records
should be sent.
BCBSKS prefers the provider faxes the records, if possible.
Providers are encouraged to respond within 10 days.
Once the records are received, BCBSKS will forward records to the member's
home plan for review.
Adjustments:
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Contact BCBSKS if an adjustment is required. BCBSKS will work with the
member’s Blue Plan for adjustments.
www.bcbsks.com
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BlueCard Program
Appeals:
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Provider may appeal on the member's behalf.
Provider should complete Claim Appeal Representative Authorization Form located
on the BCBSKS Website.
BCBSKS will forward appeal to the member's Blue Plan and notify the provider.
Other Party Liability (OPL) Claims:
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Providers file a secondary BlueCard claim to BCBSKS
When the Blue member is covered by more than one health plan and:
1. One plan is BCBSKS and one plan is another Blue Plan, then a separate claim
should be filed under each ID number.
2. BCBSKS or another Blue Plan is primary, then submit other carrier's name and
address with the claim to BCBSKS. Include the OPL information with the claim.
3. A non-Blue plan is primary and BCBSKS or another Blue Plan is secondary, then
submit the claim to BCBSKS only after receiving primary payment.
NOTE: Timely filing guidelines apply to all BlueCard claims, including those that are
secondary to another health plan.
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Availity
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Availity
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Availity
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Availity
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Electronic Inpatient Precertification
Updates:
• Requirement to submit inpatient precerts electronically has been part of the
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provider contract for many years.
Submitting precerts electronically is now a measure for the 2015 QualityBased Reimbursement Program (QBRP)
• QBRP measure is outlined in provider's contract
• Meet the measure and potentially receive increased reimbursement
• If the provider is experiencing technical difficulties with submitting the
precert electronically, then that will be taken into consideration when
analyzing whether or not the provider has met this QBRP measure.
If you are experiencing problems with accessing the BCBSKS
precert system let us know ASAP.
www.bcbsks.com
www.availity.com
Electronic Inpatient Precertification
Training & Education:
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Available as a one-on-one visit and webinars
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Available for new precert staff
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BCBSKS Electronic Precert E-learning tool coming soon. Will notify
precert staff by email when available.
Required Email Addresses:
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www.bcbsks.com
www.availity.com
Provider's precert staff will receive information/emails on the precert
system only without receiving all other email notifications through
BCBSKS eNews.
No PHI/Clinical patient information will be shared via email
Electronic Inpatient Precertification
Electronic Provider Access (EPA):
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Electronic Pre-Service Review for out-of - area providers. Providers use
local Blue Plan portals to be routed to the Home Blue Plan portal for
submitting pre-service review.
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January 2014 – EPA tool is available for 33 Blue Plans.
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July 2014 – EPA is required to be used by providers for those Blue Plans
who make it available .
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Plans may request medical records from providers if pre-service review is
not submitted electronically by the provider for those Blue Plans who make
it available.
EPA is only for initial precert; not for submitting reviews or discharge dates.
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Electronic Inpatient Precertification
Electronic Provider Access (EPA)
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www.bcbsks.com
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Providers can access EPA from the BCBSKS Web Portal (BlueAccess)
through the Pre-Service Review link.
Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
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www.bcbsks.com
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Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the
Pre-Service Review link.
Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
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www.bcbsks.com
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Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the
Pre-Service Review link.
Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
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www.bcbsks.com
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Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the
Pre-Service Review link.
Electronic Inpatient Precertification
System Requirements, Access Issues and Potential Errors
• Successful use of the electronic precertification system requires access to Availity, BlueAccess
and InterQual
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Using an Operating System or an Internet Explorer (IE) version that is not compatible; i.e. IE 10
is not compatible with InterQual.
Selecting wrong NPI. The system will not tell you that you have selected the wrong NPI, but
instead gives the provider an error message.
The provider may get a blank screen when trying to access InterQual which requires the provider
to clean their web browser history.
SAML error – problem with the single sign-on between Availity and BCBSKS. Notify BCBSKS
if you receive this error message.
If you are unable to electronically precert an inpatient stay due to system access issues,
please inform BCBSKS ASAP!
www.bcbsks.com
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Electronic Inpatient Precertification
Reminders:
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Contracting providers shall provide notice for all BCBSKS members admitted for
inpatient care. This notification will be required at one of the following:
 Prior to admission
 The day of admission
 The first working day following a weekend or holiday
BCBSKS upgrades their precertification system with the newest InterQual version
every July.
BCBSKS has a Precertification web page with tools and resources available on the
BCBSKS Website at
http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/manuals/
precertification.htm
See handout material for additional list of important reminders and contact information.
www.bcbsks.com
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Other Payer Liability (OPL)
Functions of the OPL Department:
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Determines whether services are eligible for coverage under another insurer.
Assigns primary liability with the correct carrier
Determines if worker's compensation or auto insurance is involved
Their activities help contain costs that affect rates paid by our members.
Does not coordinate with Medicare or Medicaid
Submitting an OPL Claim:
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If the member is covered under two different insurance carriers:
 File a claim with both carriers and include information regarding the other carrier
on each claim.
 When an Explanation of Benefits (EOB) is received from the first or primary
carrier, it should be sent to the secondary carrier's OPL department. It should NOT
be re-filed with another claim form.
 If two BCBSKS group policies are involved, then BCBSKS will coordinate these
for you with one filing.
 If one or both BCBSKS policies are non-group, then a claim must be filed under
each ID # separately.
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Other Payer Liability (OPL)
Timely Filing:
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Protects providers from the possibility of receiving a timely-filing denial
If it has been15 months or more from the DOS and the claim is then filed, then the
claim will be denied for not filing in a timely and will be a provider write-off
OPL and BlueCard :
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Providers should file a secondary Host claim to BCBSKS just as a claim for any
Kansas Plan member.
If the patient is covered under another Blue Plan and a BCBSKS Plan, a separate claim
will need to be filed under each ID number.
Inquiries regarding overpayments on claims paid by BCBSKS as the Host Plan that
have resulted from payment made by another carrier should be directed to our
Customer Service Center at (785) 291-4058. Do not direct these inquiries to the
OPL department.
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Other Payer Liability (OPL)
Avoiding Delays:
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Provide OPL with the information prior to or at the time of filing your claim.
A form for providers to request a deduction of OPL related overpayments is also
available.
Both the OPL Questionnaire and the OPL Deduct Authorization form can be
found on the BCBSKS Website at:
http://www.bcbsks.com/CustomerService/Providers/forms.htm
Send or fax completed forms to the BCBSKS OPL Department:
Blue Cross and Blue Shield of Kansas
Attn: OPL cc217D5
1133 SW Topeka Blvd
Topeka, KS 66629-0001
Fax to OPL: (785) 291-8981
www.bcbsks.com
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Other Payer Liability (OPL)
Reconciling your account:
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Refer to the EOBs from each carrier
Apply the following rules:
 If the patient is not an FEP member or the provider contracts with the
primary carrier, then the provider accepts primary payer's write-off.
 If the patient is an FEP member or the provider does not contract with
the primary payer, then:
 the provider determines write-off by subtracting the lesser allowance
for any contracting carrier from the total charge(s).
 the patient's responsibility is found by subtracting provider the writeoff and the primary and secondary payment from the total charge(s).
 If the patient responsibility after the primary carrier's payment is greater
than the BCBSKS allowance, then the provider must accept the
BCBSKS write-off.
• An overpayment may result when one or both policies does not
coordinate benefits and both parties pay as primary. In this case the
overpayment is refunded to the patient by the provider.
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Other Payer Liability (OPL)
Remittance Advice (RA):
• RA helps the provider in identifying a claim involving OPL.
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The BCBSKS RA for secondary payments will show:
• amount paid by the primary carrier
• amount paid on the secondary claim
• amount of patient responsibility
• total provider write-off after taking into consideration the benefits
of both carriers
This eliminates the need to retrieve the primary carrier EOB for
balancing patient accounts.
www.bcbsks.com
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Other Payer Liability (OPL)
Remittance Advice (RA):
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Listed below are specific coding combinations on the RA that helps the
provider in identifying a claim involving OPL.
OPL Code(s) on RA
Coding Details
ARC = 23
Paid as secondary carrier
ARC = 227 (16 for FEP)
RMK = N179
Awaiting a response to an OPL questionnaire sent to the patient.
ARC = 22, RMK = N598
The primary carrier must process first and an EOB for the Primary Carrier is required
(OR) the EOB from the primary carrier does not match this claim.
ARC = 23, RMK = M43
The primary carrier’s payment exceeds the amount payable under the patient’s contract.
No secondary payment is available.
ARC = 19, RMK = MA04
The service is due to a job-related illness or injury (Workman’s Compensation Applies).
ARC = 21, RMK = MA04
The service is due to a motor vehicle related accident (Automobile Insurance Applies).
ARC = 23, RMK = MA04
The patient has accepted a financial settlement form another insurance
carrier for this claim.
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Other Payer Liability (OPL)
OPL Exclusions
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BCBSKS contracts contain an exclusion section which outlines conditions
for which benefits will not be provided. Among these exclusions are:
• Worker’s Compensation
Services provided as the result of work related injury or illness will not
be covered by BCBSKS when the patient is covered (or required to be
covered) by worker’s compensation law.
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No-Fault Auto
Benefits will not be provided for services resulting from accidental
bodily injuries due to a motor vehicle accident to the extent that the
services are payable under any medical expense payment provision of
any automobile insurance policy.
Don't wait to receive a payment from these carriers, go ahead and
file the claim to BCBSKS to avoid a timely filing denial.
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Other Payer Liability (OPL)
Subrogation
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Subrogation is defined as "The substitution of one for another as creditor so
that the new creditor succeeds to the former's rights or obligations".
• Recover of payment due to a 3rd party liability.
Recoveries and inquiries into and/or regarding subrogation are outsourced
by Blue Cross and Blue Shield of Kansas to:
The Rawlings Company
One Eden Parkway
PO Box 49
LaGrange, KY 40031-0049
Providers may inquire as to whether a group has a subrogation rider through
the OPL department.
www.bcbsks.com
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2015 Policies & Procedures
Updates and Changes:
• Language was added to the provider contracts that encompasses all subsidiaries of
BCBSKS
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A new BCBSKS Subsidiary (a Health Maintenance Organization (HMO)) known as
Blue Solutions will be sold to consumers soon with an effective date of January 1,
2015:
o Blue Choice network
o Limited network with in-state contracting providers only
o Empty Suitcase
o Sold to individuals on and off the exchange and small group (SHOP) markets
o Blue Solutions is not a traditional HMO:
 Members will not choose a Primary Care Provider (PCP)
 No referral is needed for visiting a specialty provider
 Members have open access through the BCBSKS Blue Choice network
 Providers reimbursed using Blue Choice payment rates
www.bcbsks.com
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2015 Policies & Procedures
Blue Solutions
The following alpha prefixes will be used for Blue Solutions members:
XSC - Individual Exchange Solutions
XSG - SHOP Exchange Solutions
XSQ - Individual Solutions Off-Exchange
XSR - Small Group Solutions Off-Exchange
www.bcbsks.com
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2015 Policies & Procedures
Updates and Changes:
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Language was added to specify a timeframe for organizing a First Level
Appeal Panel
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BCBSKS has a credentialing program which:
• consists of an initial full review of the providers credentialing
application with re-credential at a minimum of every 36 months.
• monitors of all network providers for continual compliance with
established criteria will occur as needed, but not less than monthly.
If a provider does not meet credentialing requirements, they will not be
allowed to participate as a network contracting provider.
Providers may appeal this decision by following the appeals process
outlined in the Policies and Procedures.
Credentialing Program requires BCBSKS to have an appeals panel and
BCBSKS will have 60 days from receipt of the appeal to organize the
appeals panel.
www.bcbsks.com
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2015 Policies & Procedures
Updates and Changes:
• A section was added to the P&P to further define the confidentiality provision.
BCBSKS requires that all proprietary information be kept confidential. The contracting
provider may not disclose any terms of the Agreement to the third party except upon
written consent of BCBSKS and as required by state or federal law.
• Added language to strongly encourage contracting providers to use the Limited Patient
Waiver (LPW).
 A waiver should be used for a variety of reasons included the service is not medically
necessary, the benefit is denied per the member contract or the service is considered
Experimental or Investigational.
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Some providers have their own waivers and they may not meet BCBSKS
Requirements. If providers want to use your own waiver form to verify that it
includes everything that is on the BCBSKS waiver, then please have your BCBSKS
rep review your waiver form.
www.bcbsks.com
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2015 Policies & Procedures
Updates and Changes:
• A section was added outlining the administrative disputes process to
comply with health plan accreditation guidelines.
 This is not new; just clarification
 Provider may dispute issues of concern through their BCBSKS Rep
 Rep will work with the provider to address the dispute
 Dispute may be escalated to BCBSKS management, if unresolved
 BCBSKS will provide written response within 60 days of
management receiving the request
www.bcbsks.com
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Quality-Based Reimbursement Program (QBRP)
QBRP 2015 OUTLINE
Mailings
• Period 1:
July 11, 2014
• Period 2:
January 31, 2015
(If provider needs
another copy)
Effective
Dates
• Period 1
January 1, 2015
Letters
• Reminders:
Period 1: Oct. 29, 2014
Period 2: April 29, 2015
• Period 2
July 1, 2015
• Submission
Confirmation:
Will be emailed within 10
days of BCBSKS
receiving attestation
• Results:
Period 1: Dec. 15, 2014
Period 2: June 15, 2015
www.bcbsks.com
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Deadlines
• Must report by:
Period 1: Nov. 15, 2014
Period 2: May 15, 2015
Quality-Based Reimbursement Program (QBRP)
QBRP Forms and Notifications:
• Form can be submitted by paper or electronically.
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Electronic
form was available on BlueAccess beginning August 18th.
Paper forms can be faxed to Brent Matile @ 785-290-0734 or
emailed to Brent.Matile@bcbsks.com
Confirmation of receipt of the form will be sent within 10 days
to the provider.
Result letters will be mailed to providers within 30 days.
Details of the 2015 QBRP were in included in the provider
contract mailed in July.
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Quality-Based Reimbursement Program (QBRP)
Incentive Increases:
• Incentives earned will be applied to inpatient MS-DRG
maximum allowable payments (MAPs) and outpatient MAPs
except for reference laboratory and pharmacy and services that
have a charge less than the MAP.
QBRP Prerequisites include:
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Electronic remittance advices
Use of BCBSKS electronic portal for inpatient hospital precertification
and continued stay reviews
Obtain eligibility, benefit and claim status information primarily
through electronic transactions
www.bcbsks.com
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