Medicare Advantage PPO (FreedomBlue) - SNF
What is Medicare Advantage?
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Eligibility
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Benefits
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Telephone Numbers
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Medical Management Requirements
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Program administered by the Centers for Medicare and Medicaid Services (CMS).
Formerly called Medicare+Choice.
Provides all the same benefits of Medicare plus supplemental benefits (i.e. Vision, Dental, RX,
etc.).
FreedomBlue is a Medicare Advantage Preferred Provider Organization (PPO) product from
HighMark Blue Shield in association with Blue Cross of Northeastern Pennsylvania. It offers
Medicare-eligible individuals the convenience of a PPO arrangement through which covered
health care services are reimbursed at the highest level when member received these services
from network providers.
Permanent county residence: NEPA – Luzerne and Lackawanna counties
Eligible for Medicare Part A and enrolled in Part B
Can not be medically determined to have End Stage Renal Disease (ESRD)
Refer to attachment labeled “Freedom Blue News”
1. FreedomBlue News – Oct 05
2. FreedomBlueNews – Jan 06
SNF Benefit
1. 100 day per benefit period (60 day lapse)
2. Three (3) day prior hospital stay is NOT required
3. Authorization is required
Refer to attachment labeled “FreedomBlue Contact Information”
Medical necessity criteria are the same as Medicare (InterQual Treatment Criteria).
Authorization should be obtained prior to services being rendered or within 48 hours of the request
for an emergency admission.
To obtain authorization, contact Highmark Blue Shield’s Health Care Management Services
(HMS) Team at 1-866-731-8080.
Provider’s responsibility to obtain precert. If not obtained, corresponding claim will be rejected,
and the member must be held harmless.
Authorization required for but not limited to:
1. Hospital Inpatient Admissions
2. SNF Admissions
3. Certain outpatient surgical procedures (reference the “Procedures/DME that Require
Authorization”) They are “Procedures Requiring Authorization” and “Update to Procedures
Requiring Authorization”.
4. Select DME/P&O items
5. Therapies (PT, OT, ST, etc.)
6. Home Health Care
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Reimbursement/Billing
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Treatment Plans (Refer to attachment labeled “Therapy Treatment Plan
1. PT, OT and ST require initial Authorizations and Treatment Plans. Also, Treatment Plans
after 12th visit
2. Fax Treatment Plans to HMS at 1-866-236-6321
3. 100% coverage for PT, OT and ST after $15 copay per visit
Pre-Authorization effective 1st Qtr 2006, and applies to outpatient, non-emergency imaging
services.
1. Select CT Scans, Select MRI Scans, Select MRA Scans and all PET Scans
2. Ordering physician calls NIA prior to scheduling the test at 1-800-547-3627, Option 5
3. NIA is available M – F, 8 am to 8 pm
4. Clinical criteria available at www.RadMD.com
Transfers – Refer to attached labeled “FreedomBlue Provider Guide”, page 12.
SNF’s medical management and billing must coordinate to ensure that what is billed has been
authorized.
When benefit days are exhausted or the member no longer requires skilled care, FreedomBlue
can no longer pay for the member’s inpatient (Part A) services. New authorization required for
Part B services that will continue
NOMNC (Notice of Medicare Non Coverage) – refer to attachment labeled the same - is used to
notify member that coverage for inpatient stay will not continue.
1. NOMNC must be provided 2 day before services will be denied, reduced or terminated
2. NOMNC notifies member of their potential liability and appeal rights
Bed Hold
1. Must hold for up to 5 calendar days
2. No payment made for days member didn’t occupy room
3. Unlike FFS Medicare, member CANNOT be billed
Billing/Level of Care Guidelines – refer to attachment labeled “FreedomBlue Provider Guide”
 Level 1 corresponds to revenue code 0128
 Level 2 corresponds to revenue code 0200
 Level 3 corresponds to revenue code 0120
Hardcopy Claims (UB-92) to: FreedomBlue, P.O. Box 358, Pittsburgh, PA 15230
Electronic Claims – Please use the following:
NAIC # - 54771C
Billing Provider Qualifier - 1A
Billing Provider ID - 4 Digit Provider ID #
OR
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NAIC # - 54771C
Billing Provider Qualifier - 1C
Billing Provider ID - Medicare Number
Freedom Blue Contracted providers – refer to Medicare Advantage PPO Agreement
1. Inpatient – Level I, II and III are per diem and exclude professional services
2. Part B Only – Fee Schedule
No coinsurance or deductible will apply
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Electronic Tools
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Blues on Call
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Silver Sneakers
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Prescription Drug Discount Program
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SNF’s medical management and billing must coordinate to ensure that what is billed has been
authorized.
Consolidated billing is required (SNF reimburses vendor)
Services excluded from consolidated billing are Prosthetics, Orthotics, complex diagnostic
procedures
When Benefit Days are Exhausted OR the Member No Longer Requires Skilled Care,
FreedomBlue can no longer pay for the member’s inpatient (Part A) services. New authorization
required for Part B services that will continue.
Bed Hold
1. Must hold for up to 5 calendar days
2. No payment made for days member didn’t occupy room
3. Unlike FFS Medicare, member CANNOT be billed
Billing/Level of Care Guidelines – refer to attachment labeled “FreedomBlue Provider Guide
1. Level 1 corresponds to revenue code 0128
 Level 2 corresponds to revenue code 0200
 Level 3 corresponds to revenue code 0120
BCNEPA Provider Center (Medical Policy, Forms, Policy/Procedural Manual, etc) available via
NaviNet or Secure Access.
www.cms.hhs.gov
Procedures Requiring Authorization via BCNEPA Provider Center
1. NaviNet (BCNEPA)
2. Medicare Advantage
3. Reference Materials
4. Procedures Requiring Authorization
Members of FreedomBlue have access to Highmark Blue Shield’s 24-hour toll free health care
support resource. Blues on Call offers condition management and shared decision-making.
There is a link on Highmark Blue Shield’s website (www.highmarkblueshield.com).
Silver Sneakers is a unique exercise, physical activity and social oriented program. Offers
member free access to local community fitness centers. Encourages members, often burdened
by multiple chronic conditions, to increase their levels of physical activity and motivates them to
continue to be active.
FreedomBlue members receive instant savings on most brand name and generic drugs at Premier
Network Pharmacies throughout the service area.