Presentation on theme: "Servicing Out-of-Area Blue Members _____"— Presentation transcript:
1 Servicing Out-of-Area Blue Members _____ Anthem Blue Cross and Blue Shield3Q11 BlueCard® Webinar for Virginia ProvidersSeptember 28, 2011_________Kathy Nixon, CMA (AAMA), CPCProvider Network ManagerProvider Engagement & Contracting
2 Welcome ! Thank You! Please . . . MUTE your phone and keep it muted to avoid any distracting background noiseDo not place this call on HOLD at any timeJot down and hold all questions; we will ask you to submit your comments/questions via for response afterwardsIf 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 webinarThank You!
3 DisclaimerThe 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 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!
4 Servicing Out-of-Area Members Overview of Topics BlueCard® ProgramBlue ProductsMember ID CardsVerifying EligibilityUtilization ManagementSubmitting ClaimsClaims StatusClaims AppealsContact InformationConclusion
5 Acronyms/Terms Used in this Presentation ANTHEM Anthem Blue Cross and Blue Shield in VirginiaBCBSA National Blue Cross Blue Shield AssociationHOME Plan from which member’s policy is issuedHOST Plan where member’s care was renderedIPP Inter-Plan ProgramsITS Inter-Plan Teleprocessing ServicesMA Medicare AdvantageUM Utilization Management55
6 What is the BlueCard® Program? 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.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 What is the Value to Providers of the BlueCard® Program? The BlueCard Program brings significant value to providers:The ability to serve the approximately 92.6 million “Blue” covered members nationwideThe ability to service all of these members while contracting with only AnthemA 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.BlueCard® Eligibility Line BLUE (2583)
8 Blue Products supported by the BlueCard® Program? What are the differentBlue Products supported by the BlueCard® Program?
9 Products that the BlueCard Program Supports Traditional / Indemnity 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”.Typically includes cost-sharing features (e.g., deductibles, coinsurance or copayments).Provider is reimbursed according to Anthem’s Traditional/Indemnity contract (our “Professional Provider” agreement) whose reimbursement is the same as our PPO.
10 Products that the BlueCard Program Supports PPO – Preferred Provider Organization Significant financial incentive to members when obtaining services from a designated PPO provider.No gatekeeper (primary care physician) required.No referrals required to access PPO providers.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.
11 Products that the BlueCard Program Supports EPO – Exclusive Provider Organization Members receive no benefits for care obtained outside the network except emergency care.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.Provider is reimbursed according to Anthem’s PPO provider contract. Anthem does not offer an EPO product in Virginia.
12 Products that the BlueCard Program Supports POS – Point-of-Service/Managed Care 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.Benefits still provided when the member obtains care from any eligible provider without a referral authorization, in accordance with the terms of the contract.Provider is reimbursed according to Anthem’s PPO provider contract.
13 Products that the BlueCard Program Supports BlueWorldwide Expat® Provides medical coverage for active workers in U.S.-based companies doing business abroad.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.Provider is reimbursed according to provider’s PPO contract with Anthem.
14 Products that the BlueCard Program Supports Medicare Complementary/Supplemental (Medigap) Sold by private insurance companies to fill the “gaps” in original Medicare Plan coverage to help pay for uncovered healthcare costs.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.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.
16 Identifying Blue Members: Member ID Cards 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.Exceptions:Standalone dental ID cards have no alpha prefixStandalone vision and pharmacy ID cards have no alpha prefix when delivered through an intermediaryFederal Employee (FEP) ID cards have a single “R” prefix*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.*
17 Identifying Blue Members Member ID Cards: BlueCard Program 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.
18 Identifying Blue Members Member ID Cards: BlueCard Program (continued) The suitcase logo also provides information about the member: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 Identifying Blue Members Member ID Cards: Government Programs Some Blue ID cards do not include a suitcase logo: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)
20 Identifying Blue Members Member ID Cards: Medicare Advantage 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.
21 Medicare Advantage: Background 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.
22 Medicare Advantage: Claims and Reimbursement 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.
23 Identifying Blue Members (continued) Member ID Cards: BlueWorldwide Expat 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.
24 Identifying Blue Members Member ID Cards: International Licensees Occasionally providers may see ID cards from members of International Licensees.International Licensees include:U.S. Virgin IslandsUruguayPanamaID cards from these Licensees include:Three-character alpha prefixPossibly a benefit product logo (e.g., suitcase)
25 Identifying Blue Members Member ID Cards: Limited Benefit Products 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 nameA 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.
26 Standalone Debit Card: Combined Debit Card / Member ID Card: Identifying Blue Members Member ID Cards: CDHC & Healthcare Debit CardsMembers 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.Standalone Debit Card:Combined Debit Card / Member ID Card:
27 Blue Member’s Eligibility How to Verify aBlue Member’s Eligibility
28 Verifying Eligibility The member’s Blue Plan (HOME) maintains member eligibility information.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.BLUE (2583)Electronically through Anthem
29 How to Obtain Information on a Member’s Utilization Management Protocols: Pre-certification / Pre-Authorization and/or Medical Policy
30 Utilization Management 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 eligibilityProviders 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%20RequirementsClick “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)
36 Submitting ClaimsTo avoid unnecessary claim delays, providers need to: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, VAAlways 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.*Exception is in Northern VA when treatment is rendered in the CareFirst Service Area. DETAILS ON NEXT TWO SLIDES:
37 SERVICE AREA (West/Outside of Route 123) (East/Inside of Route 123) If Your Office Location where patient is treated is inAnd, Your Provider Contract Status (by network) is:ForANTHEM (VA) cardholders,SEND CLAIMS TO:CareFirst (DC)cardholders,SEND CLAIMS TO:For cardholders of all otherBluesSERVICE AREA(West/Outside of Route 123)YES w/ VA#1NO w/ DCANTHEM#2YES w/ DCCAREFIRSTNO w/ VA#3(East/Inside ofRoute 123)
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)
42 Claim AppealsProviders 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 portalUsing 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 FormsAnthem’s direct link to our claims appeals/disputes processes is found online under Anthem, Tools & Resources, Claims:
44 Contact InformationTelephone: (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/ediAll Mail / Correspondence:P. O. Box 27401, Richmond, VA 23279
45 SUMMARY: Reminders for Providers Anthem is your “one-stop shop” for all BlueCard claim inquiries.Utilize electronic services at Anthem’s Point of Care secure portalContact Anthem* for all claim inquiries.Take advantage of educational opportunities.Submit claims to Anthem**Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.
46 Thank You! This concludes our WEBINAR program for the 3rd 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 ifyou have questions specifically regarding today’s topic, pleasesubmit 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 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.