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A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Servicing Out-of-Area Blue Members _____ Anthem Blue Cross and Blue.

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Presentation on theme: "A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Servicing Out-of-Area Blue Members _____ Anthem Blue Cross and Blue."— Presentation transcript:

1 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Servicing Out-of-Area Blue Members _____ Anthem Blue Cross and Blue Shield 3Q11 BlueCard ® Webinar for Virginia Providers September 28, 2011 _________ Kathy Nixon, CMA (AAMA), CPC Provider Network Manager Provider Engagement & Contracting

2 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Please... MUTE your phone and keep it muted to avoid any distracting background noise Do not place this call on HOLD at any time Jot down and hold all questions; we will ask you to submit your comments/questions via for response afterwards If you find you must leave this program before the conclusion, please close out your web connection and hang up your phone to fully disconnect from the webinar Welcome ! Thank You!

3 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Thank You! The information contained in this WEBINAR was current at the time it was published or uploaded, but may be subject to change. Anthem will continue to communicate updates on an ongoing basis via our provider newsletters and web portals. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Disclaimer

4 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. BlueCard ® Program Blue Products Member ID Cards Verifying Eligibility Utilization Management 4 Servicing Out-of-Area Members Overview of Topics Submitting Claims Claims Status Claims Appeals Contact Information Conclusion

5 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Acronyms/Terms Used in this Presentation ANTHEMAnthem Blue Cross and Blue Shield in Virginia BCBSANational Blue Cross Blue Shield Association HOMEPlan from which member’s policy is issued HOST Plan where member’s care was rendered IPP Inter-Plan Programs ITSInter-Plan Teleprocessing Services MAMedicare Advantage UMUtilization Management

6 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. The national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Plan’s service area; for example, a BCBS of Ohio member travels to Virginia and receives care from an Anthem provider. It links participating healthcare providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide, through a single electronic network for claims processing and reimbursement. 6 What is the BlueCard ® Program? It equips providers with one source, their local plan (in this case Anthem Blue Cross and Blue Shield in Virginia*) for claims submission, claims payment/ adjustments, and issue resolution for patients from other Blue Plans. *Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.

7 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. The ability to serve the approximately 92.6 million “Blue” covered members nationwide The ability to service all of these members while contracting with only Anthem –A one-stop shop for all claims-related activities: submissions, inquiries, claim status, payment. –Access to member eligibility, benefits and pre-certification/ pre-authorization. –Reimbursement directly from Anthem* rather than from the member. NOTE: Out-of-area members pay only those amounts indicated as “Patient Responsibility” on provider’s remittance. Provider cannot bill these members for the difference between billed charge and Anthem’s contractual allowance. *Exception is in Northern VA when treatment is rendered in the CareFirst Service Area. 7 What is the Value to Providers of the BlueCard ® Program? The BlueCard Program brings significant value to providers: BlueCard ® Eligibility Line BLUE (2583)

8 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. What are the different Blue Products supported by the BlueCard ® Program? What are the different Blue Products supported by the BlueCard ® Program? 8

9 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 9 Typically includes cost-sharing features (e.g., deductibles, coinsurance or copayments). Basic and/or supplemental hospital and medical/surgical benefits (basic, major medical and/or add-on riders). In VA, this network is called “Par” (for Participating) and the product is called “BlueCare”. Provider is reimbursed according to Anthem’s Traditional/Indemnity contract (our “Professional Provider” agreement) whose reimbursement is the same as our PPO. Products that the BlueCard Program Supports Traditional / Indemnity

10 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 10 Significant financial incentive to members when obtaining services from a designated PPO provider. No referrals required to access PPO providers. No gatekeeper (primary care physician) required. Provider is reimbursed according to provider’s PPO contract with Anthem. This is our “Preferred Professional Provider” agreement for our “KeyCare” PPO line of products. Products that the BlueCard Program Supports PPO – Preferred Provider Organization

11 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 11 Provider is reimbursed according to Anthem’s PPO provider contract. Anthem does not offer an EPO product in Virginia. There is no primary care physician selection. Within the BlueCard Program, EPO benefits coverage is restricted to services provided by BlueCard PPO providers. EPO products may have limited out-of-area benefits. The potential for such benefit limitations is indicated on the reverse side of an EPO ID card. Members receive no benefits for care obtained outside the network except emergency care. Products that the BlueCard Program Supports EPO – Exclusive Provider Organization

12 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 12 Benefits still provided when the member obtains care from any eligible provider without a referral authorization, in accordance with the terms of the contract. Highest level of benefits received when the member obtains services from the primary care provider/group and/or complies with referral authorization requirements for care. Provider is reimbursed according to Anthem’s PPO provider contract. Products that the BlueCard Program Supports POS – Point-of-Service/Managed Care

13 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 13 Provides coverage for members enrolled in the BlueWorldwide Expat program whenever they travel home to the U.S. for visits of up to 45 days. –Claims incurred in the U.S. are processed like all other out-of-area member claims. Provides medical coverage for active workers in U.S.-based companies doing business abroad. Provider is reimbursed according to provider’s PPO contract with Anthem. Products that the BlueCard Program Supports BlueWorldwide Expat®

14 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 14 Medigap does not include Medicare Advantage (MA) products as MA is a separate program under CMS. Members with MA typically do not have Medigap because under MA, Medigap policies do not pay deductibles, co-payments or other cost- sharing. Contracted and non-contracted providers are reimbursed the Medicare allowed amount, based on where service was rendered, for Medicare covered services. Medigap does not include Medicare Advantage (MA) products as MA is a separate program under CMS. Members with MA typically do not have Medigap because under MA, Medigap policies do not pay deductibles, co-payments or other cost- sharing. Contracted and non-contracted providers are reimbursed the Medicare allowed amount, based on where service was rendered, for Medicare covered services. Regulated under federal and state laws and are “standardized.” Most claims are submitted electronically directly from the Medicare intermediary to the member’s Plan via the Medicare Crossover process. Sold by private insurance companies to fill the “gaps” in original Medicare Plan coverage to help pay for uncovered healthcare costs. Products that the BlueCard Program Supports Medicare Complementary/Supplemental (Medigap)

15 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 15 How to Identify Blue Members

16 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. *It is important for providers to ask members at each visit for their current membership ID card, as new cards may be issued throughout the year.* *It is important for providers to ask members at each visit for their current membership ID card, as new cards may be issued throughout the year.* Most Blue ID cards have a three-character alpha prefix (the first three characters of the ID number). This prefix is vital for accurate claims routing as it identifies the member’s Blue Plan. 16 Identifying Blue Members: Member ID Cards Exceptions: Standalone dental ID cards have no alpha prefix Standalone vision and pharmacy ID cards have no alpha prefix when delivered through an intermediary Federal Employee (FEP) ID cards have a single “R” prefix

17 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. BlueCard members’ ID cards have a suitcase logo, which may appear as empty or with “PPO” in the suitcase. This suitcase logo identifies the reimbursement level to the provider, not the member’s benefits. 17 Identifying Blue Members Member ID Cards: BlueCard Program

18 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. The suitcase logo also provides information about the member: 18 Identifying Blue Members Member ID Cards: BlueCard Program (continued) PPO in suitcase: –The member is enrolled in a PPO or EPO product (back of card may identify benefit limitations for EPO members). –The provider is reimbursed at the Anthem PPO reimbursement level. Empty suitcase: –The member is enrolled in a Traditional/Indemnity, HMO or POS product. –The provider will be paid at the Anthem Traditional/Indemnity reimbursement level. –Note: Anthem’s reimbursement level is the same for Traditional/Indemnity (or “Par”), and PPO, POS.

19 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Some Blue ID cards do not include a suitcase logo: 19 Government-Wide Service Benefit Plan (also known as the Federal Employee Program or FEP) Medicare Complementary/Supplement (also known as Medigap) Medicaid (claims are priced at the member’s state Medicaid rate) State Children’s Health Insurance Program (also known as SCHIP- payment is limited to the member’s state SCHIP reimbursement rate) Identifying Blue Members Member ID Cards: Government Programs

20 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Providers can recognize Medicare Advantage members by one of these logos on the ID card. The text “Medicare charges might apply” will appear on either the front or back of the card. 20 Identifying Blue Members Member ID Cards: Medicare Advantage

21 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Medicare Advantage (MA) is a government program under which Medicare beneficiaries can opt out of traditional Medicare and enroll with a private insurance carrier, such as a Blue Plan. Once a Medicare beneficiary opts out of traditional Medicare and elects a Medicare Advantage plan, the coverage (both primary and secondary combined) is provided by the private insurance carrier. The MA member continues to pay their Medicare Part B premium and, if applicable, a premium to the private insurance carrier. MA products must cover, at a minimum, the same services as original Medicare (Parts A and B) and often offer additional benefits like vision and dental, and/or may cover deductibles/coinsurance. 21 Medicare Advantage: Background

22 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Blue Medicare Advantage (MA) claims are sent by the provider to Anthem. Claims where a Medicare Advantage PPO member was treated by a Medicare Advantage PPO provider are considered MA PPO in-network claims and are reimbursed according to Anthem’s MA PPO contract with the provider, both for local MA members and other out-of-area Blue MA members. Contact your local Anthem Network Manager for contracting information. Non-network MA providers’ claims are priced at the standard Medicare allowed amount based on where services are rendered. 22 Medicare Advantage: Claims and Reimbursement

23 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Providers may see patients enrolled in the BlueWorldwide Expat product: –Medical coverage for employees of U.S. companies who are based abroad. –Includes coverage when employees temporarily return to the U.S. for up to 45 days per visit. ID cards include the three-character alpha prefix. 23 Identifying Blue Members (continued) Member ID Cards: BlueWorldwide Expat

24 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Occasionally providers may see ID cards from members of International Licensees. International Licensees include: –U.S. Virgin Islands –Uruguay –Panama ID cards from these Licensees include: –Three-character alpha prefix –Possibly a benefit product logo (e.g., suitcase) 24 Identifying Blue Members Member ID Cards: International Licensees

25 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. A limited benefit product is a healthcare plan that has an annual maximum benefit of $50,000 or less per covered member, not including amounts, if any, for dental or vision benefits. Members who have Blue limited benefit product coverage carry ID cards that may have one or more of the following indicators: –One of these product names: ›InReach, MyBasic or some other non-Blue name –A green stripe at the bottom of the card. –A statement either on the front or the back of the ID card stating this is a limited benefit product. –A black cross and/or shield to help differentiate it from other ID cards. 25 Identifying Blue Members Member ID Cards: Limited Benefit Products

26 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Members with Consumer-Directed Healthcare (CDHC) plans often carry healthcare debit cards to allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). Some ID cards are standalone debit cards that cover eligible out-of-pocket costs; others also serve as the member’s ID card. In some cases, the card will display the Blue Cross and Blue Shield trademarks, along with the logo from a major debit card (e.g., MasterCard®, Visa®). The cards include a magnetic stripe allowing providers to swipe the card at the point-of- service and collect the member cost-sharing amount. 26 Identifying Blue Members Member ID Cards: CDHC & Healthcare Debit Cards Standalone Debit Card:Combined Debit Card / Member ID Card:

27 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 27 How to Verify a Blue Member’s Eligibility How to Verify a Blue Member’s Eligibility

28 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Providers may verify member eligibility and coverage information by calling the BlueCard Eligibility Line: BLUE (2583) or electronically through Anthem’s secure portal, Point of Care. The member’s Blue Plan (HOME) maintains member eligibility information. 28 Verifying Eligibility BLUE (2583) Electronically through Anthem

29 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 29 How to Obtain Information on a Member’s Utilization Management Protocols: Pre-certification / Pre-Authorization and/or Medical Policy

30 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. The member’s Plan maintains their utilization management information, including any applicable pre-certification/pre-authorization requirements and medical policy. For out-of-area members (commonly referred to as “BlueCard members”) obtaining pre-certification/pre-authorization is ultimately the member’s responsibility; however, most providers coordinate this on the member’s behalf. Providers can obtain pre-certification/pre-authorization information when calling the BlueCard Eligibility Line: BLUE ( ) to verify eligibility Providers also have access to the member’s Plan’s general pre-certification/pre- authorization requirements through the Medical Policy and Pre-certification/Pre- authorization “Router” found on the open provider portal of Anthem’s website. –Enter the middle blue “tout” on the left of any screen; click on either option for “out of area” and then enter the alpha prefix: el=Coverage%20%26%20Clinical%20UM%20Guidelines,%20and%20Pre-Certification%20Requirements el=Coverage%20%26%20Clinical%20UM%20Guidelines,%20and%20Pre-Certification%20Requirements –Click “continue” and this will route provider to that member’s plan’s website where their policy and UM requirements reside (provider may view but cannot perform the auth request from here) 30 Utilization Management

31 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 31

32 A presentation of the Blue Cross and Blue Shield Association. All rights reserved.

33 EXAMPLE “XYZ”

34 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. EXAMPLE “XYZ” takes you to BCBS of Michigan where you can continue to view medical policy/precert info or just use this functionality to learn the HOME plan for prefixes you cannot identify.

35 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 35 How/Where to Submit Claims for Blue Members How/Where to Submit Claims for Blue Members

36 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Submit claims to Anthem* and use appropriate coding as instructed by Anthem. (As the local or HOST Plan, our coding, billing guidelines, and contractual pricing applies, whereas the member’s HOME Plan governs benefits and medical management requirements.) Electronically submitted claims (837s) will come into our gateway and be routed via ITS to the member’s plan; Paper claims should be mailed to P. O. Box 27401, Richmond, VA Always submit claims with only valid alpha prefixes. Include Other Party Liability (OPL) information on the claim if there is an indication of more than one payer. Send medical records timely and as instructed by Anthem (wait for our letter requesting the specific records needed) Do not send duplicate claims. To avoid unnecessary claim delays, providers need to: 36 Submitting Claims *Exception is in Northern VA when treatment is rendered in the CareFirst Service Area. DETAILS ON NEXT TWO SLIDES:

37 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. If Your Office Location where patient is treated is in  And, Your Provider Contract Status (by network) is: For ANTHEM (VA) cardholders, SEND CLAIMS TO: For CareFirst (DC) cardholders, SEND CLAIMS TO: For cardholders of all other Blues SEND CLAIMS TO: SERVICE AREA (West/Outside of Route 123) YES w/ VA #1 NO w/ DC ANTHEM YES w/ VA #2 YES w/ DC ANTHEMCAREFIRSTANTHEM NO w/ VA #3 YES w/ DC ANTHEMCAREFIRSTANTHEM SERVICE AREA (East/Inside of Route 123) YES w/ VA #1 NO w/ DC ANTHEMCAREFIRST YES w/ VA #2 YES w/ DC ANTHEMCAREFIRST NO w/ VA #3 YES w/ DC CAREFIRST

38 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Anthem’s Service Area CareFirst’s Service Area

39 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 39 How to Verify Claim Status

40 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 40 Verifying Claim Status Allow Anthem 30 days for claims processing before following up. For Medicare Crossover claims, allow 30 days from when you submitted the claim to Medicare before following up on the claim. Do not submit a MedSup claim to Anthem before receiving a Medicare remittance notice. Check claims status through Anthem’s website via Point of Care or by calling the Anthem Provider Call Center at and follow the appropriate prompts (the member’s ID # prefix will route inquiry to our BlueCard department)

41 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 41 Claim Appeals Process

42 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Providers in VA who wish to communicate about a processed claim must use the Anthem “Claim Information / Adjustment Request Form #151” –Electronically through the Point of Care secure portal Using the Claims Inquiry function for a specific claim will automatically transfer the claim’s demographics directly to the #151 where the provider can just enter their remarks/comments and submit online, if no supporting documentation is required. The response will be returned online in the POC 151 section. –Manually by downloading a blank copy from the open portal under Anthem, Tools & Resources, then Provider Forms Anthem’s direct link to our claims appeals/disputes processes is found online under Anthem, Tools & Resources, Claims: htm&state=va&rootLevel=3&label=Claims&state=va&rootLevel= htm&state=va&rootLevel=3&label=Claims&state=va&rootLevel=3 Claim Appeals 42

43 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. 43 Contact Information

44 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Telephone: (800) ; Select “2” and follow prompts – member’s ID prefix will route you to our local BlueCard area. EDI Solutions HELP DESK: Phone: (800) ; Fax (804) Live Chat: anthem.com/edi All Mail / Correspondence: P. O. Box 27401, Richmond, VA Contact Information

45 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. Anthem is your “one-stop shop” for all BlueCard claim inquiries. 45 SUMMARY: Reminders for Providers *Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.

46 A presentation of the Blue Cross and Blue Shield Association. All rights reserved. This concludes our WEBINAR program for the 3 rd quarter of We hope you found the information helpful and that your time has been well spent. If you wish to comment about your experience today and/or if you have questions specifically regarding today’s topic, please submit an with “Anthem 9/28/11 Webinar: BlueCard” in the subject line to: and be sure to include your detailed contact information so we may reply back to you appropriately. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Thank You!


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