Highmark Blue Cross Blue Shield WV
May 15, 2014
HEALTH CARE EXCHANGE/ MARKETPLACE
WHAT IS IT?
The Affordable Care Act (ACA) requires that each state establish an online
marketplace, referred to as a health insurance marketplace or exchange, through which
qualified individuals may enroll in qualified health plan coverage. Eligible individuals
that qualify for financial assistance to purchase coverage must purchase their
coverage through a marketplace in order to receive the cost savings, which may
include advance premium tax credit or cost-sharing reductions for those individuals
who qualify.
The marketplaces, or exchanges, were scheduled to permit consumers in each state to
begin the plan selection and enrollment process as early as October 1, 2013 for
coverage that began January 1, 2014, the date when the individual coverage mandate
became effective.
Health insurance marketplaces will support functions other than permitting qualified
individuals to shop for qualified health plans. Consumers can also find out if they are
eligible for public health programs such as Medicaid, and they can take steps to enroll
in those programs.
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Health Care Exchange Products
Our Products & Formularies
ACA sets the requirements for Qualified Health Plans (QHPs) in terms of metal levels, out-of-pocket
maximum limits, essential health benefits and more. Health plans on the exchanges are offered in a
tiered format with several plans in each tier to choose from. Plan tiers are based on metal levels that
match the percentage of costs covered (the actuarial value of the plan) as follows:
Bronze (60 percent)
Gold (80 percent)
Silver (70 percent)
Platinum (90 percent)
Essential health benefits must be covered under each tier.
• ambulatory patient services
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance use disorder services, including behavioral health treatment
• prescription drugs
• rehabilitative and habilitative services and devices
• laboratory services
• preventive and wellness services and chronic disease management
• pediatric services, including oral and vision care
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Health Care Exchange Products
Helpful Tips……..
• No separate contract agreements to participate
• Follows Highmark WV Commercial Network
Medical Policies
Authorization process
Management programs
Services requiring authorization
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Highmark Member Cards
Cards will look the same as other lines of business for Highmark
WV. Copays will be listed but not metallic tier.
NaviNet should be utilized to verify eligibility and covered benefits.
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How will this affect you and your provider….
THE 90-DAY GRACE PERIOD
The Affordable Care Act (ACA) requires a 90-day premium delinquency
grace period for individuals who purchased insurance through the Health
Insurance Marketplace (HIM) and received an Advanced Premium Tax
Credit (APTC).
Within this 30-day period, the member is placed in delinquency and the
first delinquency letter is sent to the member. Claims are still being paid
to providers at this point.
After 60 days with no premium payment(s) made, a second delinquency
letter will be sent to the member, with the future termination date if
payment is not made in full. Claim payment to providers is suspended
at this point.
Alpha Prefixes
Specific to Market
Place Policies
(subject to change)
ZPL-On
Exchange
ZPI- Off
Exchange
If 90 days pass and the account is not paid up to date, the member's
coverage will be terminated and the claims rejected for payment back to
the provider. Once a member's coverage is terminated for nonpayment of premiums, he/she is responsible for claim payment to
the provider.
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PROVIDER RELATIONS REPRESENTATIVES
SERVICING AREAS – January 1, 2014
MELANIE
CLYDE
(304) 547-2229
SHERRI
DEAN
(304) 424-7719
JOE
LIPPOLI
(304-547-2264)
MARY
DELAROSA
(304) 347-7799
JAMIE
RAY
(304) 347-7792
05 Brooke
15 Hancock
26 Marshall
31 Monongalia*
35 Ohio
09 Doddridge
18 Jackson
37 Pleasants
43 Ritchie
48 Tyler
53 Wirt
52 Wetzel
54 Wood
44 Roane
02 Berkeley
12 Grant
14 Hampshire
16 Hardy
19 Jefferson
29 Mineral
33 Morgan
36 Pendleton
39 Preston
31 Monongalia*
10 Fayette
13 Greenbrier
24 McDowell
28 Mercer
32 Monroe
34 Nicholas
38 Pocahontas
41 Raleigh
45 Summers
51 Webster
55 Wyoming
03 Boone
06 Cabell
22 Lincoln
23 Logan
27 Mason
30 Mingo
40 Putnam
50 Wayne
07 Belmont, OH
15 Columbiana, OH
41 Jefferson, OH
56 Monroe, OH
05 Athens, OH
84 Washington, OH
58 Morgan, OH
61 Noble, OH
01 Allegany, MD
11 Frederick, MD
12 Garrett, MD
22 Washington , MD
03 Alleghany, VA
09 Bath, VA
11 Bland, VA
14 Buchanan, VA
23 Craig, VA
35 Giles, VA
45 Highland, VA
89 Tazewell, VA
10 Boyd, KY
64 Lawrence, KY
77 Martin, KY
98 Pike, KY
27 Gallia, OH
44 Lawrence, OH
53 Meigs, OH
30 Green, PA
26 Fayette, PA
08 Augusta, VA
22 Clarke, VA
34 Frederick, VA
53 Loudoun, VA
79 Rockingham, VA
82 Shenandoah, VA
JAMI
WITT-LEWIS
(304) 347-7695
04 Braxton
07 Calhoun
08 Clay
11 Gilmer
20 Kanawha
CINDY
GORBY
(304)-917-7604
01 Barbour
17 Harrison
21 Lewis
25 Marion
42 Randolph
46 Taylor
47 Tucker
49 Upshur
* Melanie Clyde and Joe Lippoli share Mon County – Melanie is responsible for WVU Hospital and connected Physicians as
well as Mon General and connected physicians.
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Highmark West Virginia website
www.highmarkbcbswv.com
•
Resource Center
•
Health Care Reform
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NETWORK PARTICIPATION
• The WVFH network is an extension of the Highmark BCBS WV PPO
Network. Existing PPO providers who participate with Medicaid are
offered participation with WVFH by agreeing to the amendment of the
current agreement with Highmark WV
• Reimbursement for covered services is 105% of West Virginia
Medicaid
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Primary Care Providers
Each West Virginia Family Health member will choose a Primary Care
Practice as their Patient Centered Medical Home.
The PCP works in conjunction with the member to coordinate all
appropriate medical care.
Members are able to change PCP’s on a monthly basis if requested.
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Referrals
In certain instances, members do not require a referral from the PCP to see
a network specialty care practitioner.
Members may self refer for the following services:
•
•
•
•
•
•
OB/GYN Services
Family Planning Services (Family Planning services do not have to be
rendered by a Network provider)
Dental services
Routine vision
Chiropractic services (an authorization must be obtained by the
chiropractic office, including the initial evaluation)
Mental health/substance abuse services
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Claims and Billing
•
Bill all appropriate modifiers
•
Bill all encounters, regardless of payment expected
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Timely filing Criteria
₋
Initial Bills must be received within 12 month of date of service or payment from the
primary carrier.
•
₋
•
All EPSDT claims and primary care services should be submitted within 60 calendar days from the date
of service to permit accurate member outreach.
Corrected claims or requests for review must be received within 180 days from the date
of the remittance advice
Claims submitted with any attachments, such as EOBs from Primary
Carriers must be submitted on paper
West Virginia Family Health – Claim Department
P.O. Box 69319
Harrisburg, Pa. 17106
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Claims and Billing
Electronic Billing
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•
Electronic claims accepted through Emdeon or Relay Health
Please refer to the following grid for Emdeon Payer ID’s and RelayHealth
CPID’s (clearinghouse Process ID):
CPID
PAYER NAME
PAYER ID
CLAIM TYPE
45276
West Virginia Family Health
(WVFH)
45276
Professional
45276
West Virginia Family Health
(WVFH)
45276
institutional
•
•
Hospital should include their West Virginia Family Health issued legacy
number in your 837I submissions
• Loop 2010BB REF01 with a qualifier of 'G2‘
• REF02 should be WVFH Issued ID#
PCP’s and Specialists should bill under their individual NPI#
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WVFH PROVIDER RELATIONS REPRESENTATIVES
SERVICING AREAS - January 1, 2014
Melissa Johnson
304-547-2267
Melissa.johnson@highmark.com
Alana DeJesus
304-347-7692
Alana.dejesus@highmark.com
05 Brooke
15 Hancock
26 Marshall
31 Monongalia
35 Ohio
52 Wetzel
09 Doddridge
02 Berkeley
12 Grant
14 Hampshire
16 Hardy
19 Jefferson
29 Mineral
33 Morgan
36 Pendleton
39 Preston
37 Pleasants
43 Ritchie
48 Tyler
01 Barbour
21 Lewis
25 Marion
17 Harrison
42 Randolph
46 Taylor
47 Tucker
49 Upshur
04 Braxton
18 Jackson
07 Calhoun
08 Clay
11 Gilmer
53 Wirt
20 Kanawha
54 Wood
44 Roane
03 Boone
06 Cabell
22 Lincoln
23 Logan
27 Mason
30 Mingo
40 Putnam
50 Wayne
10 Fayette
13 Greenbrier
24 McDowell
28 Mercer
32 Monroe
34 Nicholas
38 Pocahontas
41 Raleigh
45 Summers
51 Webster
55 Wyoming
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West Virginia Family Health Website
www.wvfh.com
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Policy & Procedure Manuals
•
Complete Formularies
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Online Provider Directory
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WVFH Forms
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ATTENTION SKILLED NURSING HOMES
• Highmark has engaged the services of the Matrix Medical Network
to help us complete health risk assessments for Medicare
Advantage Plan beneficiaries
• There is no cost to the member
• Assessments help Highmark on-going commitment to quality care
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Highmark WV Workshop Schedule
June 10th
Charleston Marriott Salons A&C on the 2nd floor
June 11th
Huntington Pullman Plaza Virginia/Maryland Rooms
June 17th
Bridgeport Conference Center Ballroom
June 18th
Wheeling Oglebay Conference Center Wilson Lodge
Banquet Rooms 1, 2 and 3
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FY 2015 Quality Blue Hospital Program Focus
Streamlined to Six Components
Quality Bundle
• Hospital employed physician practices quality of care metrics
Readmissions
• Acute Care 3 and 30 day readmissions
• return to ED within 7 days following acute care discharge
Healthcare Associated Adverse
events (HAAE)
Advance Care Planning and/or
Palliative Care for Complex Patients
Perinatal
Efficiency Measure (Medicare
Spending Per Beneficiary –MSPB)
• Healthcare Associated Infections (HAI): CDC-NHSN data
• Venous thromboembolism
• Palliative care consults for targeted populations
• (POLST/POST) for SNF and LTAC discharges
• Low risk birth mothers C-section rate (AHRQ IQI 33)
• CMS Medicare Spending Per Beneficiary Ratio
2121
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Measures included in the Quality Bundle: 20 CMS Star Measures
C01
Breast Cancer Screening
C20
Disease Modifying Anti- Rheumatic Drug
Therapy for Rheumatoid Arthritis
C02
Colorectal Cancer Screening
C23
Plan All-Cause Readmissions : Medicare
Advantage
C03
Cholesterol Management for Patients with
Cardiovascular Conditions: LDL-C Screening
D11
Use of High Risk Medication in the Elderly
C04
Comprehensive Diabetes Care: LDL-Cscreening
D12
Diabetes: Appropriate Treatment for
Hypertension
C10
Adult BMI Assessment
D13
Medication Adherence for Diabetes
Medication
C14
Osteoporosis Management in Women who
had a Fracture
D14
Medication Adherence for Hypertension:
Renin Angiotensin System Antagonists
(RASA)
C15
Comprehensive Diabetes Care: Eye exam
( retinal) performed
D15
Medication Adherence for Cholesterol
(Statins)
C16
Comprehensive Diabetes Care : Medical
attention for nephropathy
C51
Annual Wellness and Initial Preventive
Physical Exam Rate
C17
Comprehensive Diabetes Care: HbA1c
Control ( ≤9%)
DMC 16 Exacerbation: Systemic Corticosteroid within
Comprehensive Diabetes Care: LDL-C
Control ( < 100 mg/dL)
DMC17 Exacerbation: Bronchodilator within 30 days
C18
Pharmacotherapy Management of COPD
14 days
* Measures in blue
denote Static measures
Pharmacotherapy Management of COPD
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Highmark WV Quality Blue Hospital Program
Participants
Current Participants
Future Participants
United Hospital Center
Berkeley Medical Center
Camden Clark Medical Center
Jefferson Medical Center
West Virginia University Hospital
Monongalia General
Fairmont General
Logan General
Cabell Huntington Hospital
Weirton Medical Center
Wheeling Hospital
Bluefield Regional [FY2016]
Thomas Memorial
St. Francis
Greenbrier Valley Medical Center
Princeton
Raleigh
Pleasant Valley
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THANK YOU
For questions or additional information please contact:
Joyce Landers
Cindy Heiskell
304-347-7730
304-347-7717
joyce.landers@highmark.com
cindy.heiskell@highmark.com
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