3 HEALTH PLAN UPDATES BCNEPA Jean WiernuszConsultant, Provider Relations
4 Health Plan Updates - BCNEPA General Updates- Community Behavioral Healthcare Network of PA (CBHNP) has changed itsname to PerformCare as of 10/1/13-Annual Provider Satisfaction Survey has been sent. Please complete and returnif you haven’t already done so-Remind your patients to get their flu shot. Note: Nasal spray vaccine is onlycovered for patients age 2-49; Intradermal vaccine is NOT covered
5 Health Plan Updates - BCNEPA Please Comply with Medical Records Requests-Quality reporting for HEDIS-Medical Necessity Review-Claim Auditing-Trover Solutions, Inc. has been contracted to review high-cost drugs, biologics, DME and P & O claims-Unlisted or NOC Code Submissions-Insurers must provide medical record documentation related to risk adjustment tothe Department of Health and Human Services-BCBSA has contracted with Verisk Health to provide an efficient, centralized process tocoordinate medical record requests from Blue Cross and/or Blue Shield companiesacross the country to held reduce multiple requests for patient data-Verisk is contractually bound to preserve the confidentiality of health plan members’PHI under HIPAA regulations, and no patient authorizations/releases are required foryou to comply with these requests
6 Health Plan Updates - BCNEPA Suboxone UpdateFPH/FPLIC covers suboxone treatment. Coverage includes all professional office visits and med checks and services should all be submitted to FPH/FPLIC directly effective 1/1/14.The medication itself is a pharmacy benefit and requires a special prior authorization request completed by the ordering physician.
7 Health Plan Updates - BCNEPA Electronic Data Interchange (EDI)- EDI is for both professional and institutional providers who wish to file claims to BCNEPA electronically through a clearinghouse. The EDI Registration Form can be found on our Provider Center.
8 Health Plan Updates - BCNEPA -EFT/ERA-Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) areavailable for FPH, FPLIC and BCNEPA-ERA files are sent to you via your clearing house or NaviNet and yoursoftware vendor will provide instruction to download this file to postpayments directly to your patient accounts-Missing or late EFT – Contact Provider Relations and provide TIN and NPI-Missing or late ERA – Contact your designated clearing house and/orProvider Relations and provide your TIN, NPI and clearinghouse name
9 Health Plan Updates - BCNEPA UB-04 Claim Submission-Updated Patient Discharge Status Codes (Field Locator 17)-Intentional readmission language has been added-Changes to Type of Bill (Field Locator 04)-Type 033x eliminated; Type 032x, 034x and 089x were revised-Condition Codes (Field Locator 18-28)-New codes for C-section and induction services-Revenue Codes (Field Locator 42)-0953 New – chemical dependency; 1001 and 1002 were revised-069x New – pre-hospice/palliative care services (effective 1/1/14)
10 Health Plan Updates - BCNEPA -New 1500 Claim Form (2/12) Approved-Transition Timeline:-1/6/14 – Payers will begin to accept the revised form-1/6/14 to 3/31/14 – Payers will accept both versions (8/05 or 2/12)-4/1/14 – Payers will accept only version 2/12-Bill Frequency Codes for 1500 Claim Adjustments-“7” Replacement of prior claim-“8” Void/cancel of prior claimThe FPH Claims Research Request Form is no longer required when submitting adjustments using the codes above
11 Health Plan Updates - BCNEPA Radiology Utilization Management Program –National Imaging Associates (NIA)-Prior authorization of non-emergent, advanced, outpatient radiology services-BCNEPA-NIA radiology benefit management program will now apply to:FPH and FPLIC fully insured, FPH and FPLIC individual products (excluding Special Care and Blue Care Security), CHIP members and select self-funded groups-Imaging services performed in the following settings do not require priorauthorization through NIA: emergency room, observation, inpatient andurgent care centers.-It is the responsibility of the ordering physician to obtain authorization.-Providers rendering the above services should verify that the necessaryauthorization has been obtained. Failure to do so may result in non-paymentof your claim.
12 Blue Distinction Centers Blue Distinction Centers are part of a national designation program that recognizes hospitals that demonstrate expertise in delivering quality specialty care safely and effectively in the areas of: Bariatric Surgery, Cardiac Care, Complex and Rare Cancers, Knee and Hip Replacement, Spine Surgery, and Transplants
13 Blue Distinction Centers Blue Distinction Centers (BDC)What does it mean to be a BDC?-The Blue Distinction Center must meet quality-focused criteria thatemphasize patient safety and outcomes.-Facilities currently designated as BDC must have in-network status. AllHospital Based Physicians and Key Specialists (who are likely to provideservices related to the Blue Distinction Center specialty care designation)will be required to have in network status, except as prohibited by law.
14 Blue Distinction Centers Blue Distinction Centers + (BDC+):The program was expanded to add another level of designation, Blue Distinction Centers +. BDC+ must meet the same quality-focused criteria that emphasize patient safety and outcomes, as well as being cost efficient.
15 Blue Distinction Centers Where can I find a list of the Blue Distinction Center facilities?Go to-“Find a Doctor/Hospital”-“Blue Distinction”
16 Blue Distinction Centers Blue Distinction Centers for Transplants Facilities (BDCT)Patients have access to nearly 100 Blue Distinction Centers for Transplants across the country which include:-heart-lung (single/bilateral)-liver (deceased/living donor)-simultaneous pancreas kidney (SPK)- pancreas transplant alone (PTA)-pancreas after kidney transplant (PAK)- bone marrow/stem cell (autologous & allogeneic)-and kidney (only in conjunction with SPK/PAK)
17 Blue Distinction Centers Blue Distinction Centers for Transplants (BDCT) are network facilities for:-First Priority Health (FPH)FPH members must use a BDCT facilities specifically designated for the specific transplant type for services to be covered. There is no coverage for services provided by a Non-Participating Provider or at a Blue Distinction Transplant facility that has not been specifically designated for the specific transplant type.-First Priority Life Insurance Company (FPLIC)FPLIC EPO and Blue Care Direct members must use BDCT facilities specifically designated for the specific transplant type for services to be covered at the highest level of benefits.-Blue Cross Products
18 Blue Distinction Centers -BDCT facilities are also available for the other FPLIC plans (e.g., BlueCare PPO or BlueCare Traditional, etc.), and providers are encouraged to refer members there for high quality care.-If referring a transplant or potential transplant member to a BDCTfacility for evaluation/consultation, please call the Utilization Care Department of BCNEPA at
19 Quality Incentive Program (QIP) Changes: Effective 1/1/2014 for PCP’s Administrative measures are being eliminated, including:-Board Certification Status-Electronic Funds Transfer-Extended Office Hours-CMS Physician Incentive Programs-NCQA Recognition Programs-Access to Care (Open to new members)-Council For Affordable Quality Healthcare (CAQH)Quality measures are being revised
20 PCP Quality Measures Effective 1/1/14 -MMR Vaccination-Varicella Vaccination-Breast Cancer Screening-Colorectal Cancer Screening-Cervical Cancer Screening-Chlamydia Screening in Women-Appropriate Testing for Children with Pharyngitis-Appropriate Treatment for Children with UpperRespiratory Infection (URI)-Avoidance of Antibiotic Treatment in Adults withAcute Bronchitis-LDL-C Screening for Patients with Coronary ArteryDisease (CAD)-Diabetes HbA1c test-Diabetes LDL-C Screening-Diabetes Eye Exam-Diabetes Microalbumin Test
21 BCNEPA RemindersProvider Center – Our BCNEPA Provider Center is a great resource for important information and updates.Please check the Provider Center site via NaviNet orfor bulletins, manuals, forms, andpolicies among many other things.
23 Health Plan Updates -Highmark Radiology Utilization Management Program –National Imaging Associates (NIA)-6 procedure codes added to program effective 1/13/14– Neck CT– Face MRI, Orbits MRI, Sinus MRI– Cervical Spine CT– Lumbar Spine CT– Hip CT, Leg CT, and Lower Extremity CT– Abdomen MRIREMINDER: Providers must be privileged by NIA to perform radiologystudies on Highmark Freedom Blue members
24 Health Plan Updates - Highmark Updates to Outpatient Procedures/Services Requiring Authorization-Effective 9/2/13:2 private duty nursing codes were added-Effective 10/28/13:4 codes for sleep studies were added-Effective 1/1/14:16 hysterectomy procedure codes being added1 code being deleted (G0423 Intensive cardiac rehabilitation)
25 Health Plan Updates - Highmark Keep Your Provider File Information Current-Effective 11/1/13, claims with incorrect provider information will be rejected-Verify your information-Confirm your TIN and NPI-Updates can be made via Highmark NaviNet ; Select “Provider FileMaintenance” from the Plan Central menu-Remember that new providers may need to be credentialed before theycan be added; Contact your BCNEPA Provider Relations Consultant tobegin the application process
26 Health Plan Updates - Highmark Outpatient Behavioral Health Fee Schedules Were Adjusted-Changes were effective 11/1/13-Apply to both commercial and Medicare Advantage productsSimplified Co-payments and Visit Counts effective 9/1/13-Applies to physical, occupation and speech therapy and spinalmanipulation-Only 1 co-payment will be applied per date of service per provider-Only 1 visit will be counted per date of service per providerNote that visit limits are still applicable
27 Health Plan Updates - Highmark Physical Medicine Management Program Reminders:Two components:Care RegistrationCare AuthorizationReminder:-Authorization is a determination of medical necessity only and does not guarantee coverage or payment.-Claims for services provided without an authorization will be denied and member will be held harmless.
28 Health Plan Updates - Highmark Independence Blue Cross (IBC) Personal Choice Changes-Effective 11/1/13, professional claims for Personal Choice membersseen locally will be processed by Highmark as BlueCard claims-DME and P&O Providers should submit claims according to the BlueCardAncillary Guidelines which are available on the Provider ResourceCenter-If your claim system is programmed to submit claims for patients withIBC Personal Choice alpha prefixes, you should now direct those claimsto Highmark (NAIC 54771) for dates of service on or after 11/1/13
29 Health Plan Updates – Highmark Medicare Advantage -CMS created 42 new, non-payable procedure codes (G-codes)and 7 new non-payable severity/complexity modifiers to be usedwhen billing outpatient therapy services-Effective 1/1/14, these new codes will be required on all Physical,Occupational and Speech Therapy claims-A complete listing of the new codes and modifiers appeared in anOctober Special Bulletin which may be found on the ProviderResource Center
30 Health Plan Updates – Highmark Medicare Advantage 2014 Medicare Advantage Premiums and Benefits-Premium changes are minimal – monthly increases are less than $10 inmost cases-For most members, there are no changes to copayments for visits andprescription drugs-Oxygen and oxygen-related equipment and supplies will be subject toco-insurance effective 1/1/14-The annual deductible has decreased for the Freedom Blue PPO HighDeductible plan and a closed formulary has been added-Members will continue to have access to one of the largest and rapidly growingnetworks of doctors, hospitals, and other health care providers in theregion
31 Health Plan Updates – Highmark Medicare Advantage Medicare Advantage Medical Policies – Effective 10/14/13The following medical policies are applied to outpatient services provided by a facility to Freedom Blue PPO members:-Radiation Therapy Services-Stereotactic Body Radiation Therapy-PET and PET/CT Scans Used for Non-oncologic Conditions-PET and PET/CT Scans Used for Oncologic Conditions-Proton Beam Therapy-Stereotactic RadiosurgeryPlease review the April 10, 2013 bulletin, MAPROV C for information about the application of these medical policies to facilities. It defines the policy effective date and describes what happens if the medical necessity criteria of the policy are not met.
32 Health Plan Updates – Highmark Medicare Advantage Government Budget Sequestration UpdateEffective 1/1/14, sequestration payment adjustments will be applied to all Highmark Medicare Advantage payments after determining:-Member coinsurance-Any applicable member deductible-Any applicable Medicare secondary payment adjustmentsThe Medicare Advantage Fee Schedule will remain unchanged.
34 MEDICAL MANAGEMENT Irene Swartwood Julie Cohen Supervisor, Medical PolicyJulie CohenDirector, Utilization Management
35 MEDICAL MANAGEMENT Goal: -To ensure medically appropriate allocation of the community’s medical resources-By evaluating requests for services from contracted practitioners and providers and-applying to the benefit design, nationally established medical criteria and/or medical policy in order to-determine medical necessity, intensity of services and benefit coverage
36 DEVELOPMENT OF BCNEPA MEDICAL POLICY -Identification of technology for assessment based upon needs of customers andclinical importance-Evaluation of new technology and the new applications of existing technology-Utilize BCBSA TEC Assessments to determine clinical effectiveness andappropriateness-Conduct extensive literature searches from regulatory bodies-Review BCBSA’s Medical Policy Reference Manual-Participate in monthly BCBSA Medical Policy Panel discussions and updatepolicies accordingly
37 DEVELOPMENT OF BCNEPA MEDICAL POLICY (Cont.) - Ongoing review of pertinent research from other sources:-Centers for Medicare and Medicaid Services (CMS)-Food and Drug Administration (FDA)-Specialty Societies Consensus Documents-Agency for Healthcare Research and Quality (AHRQ)-Highmark Medical Policy- Confer with BCNEPA Medical Directors regarding concerns- Refer requests for local coverage determinations to BCNEPA Patient CareManagement Committee- Evaluate policies for safety, efficacy, cost-effectiveness, ethical and legalimplication
38 Blue Cross Blue Shield Association (BCBSA) Guidance -A cohesive force that brings 37 independent Plans together in anational system-Serves the common needs of the Plans by making recommendationson strategy, policy and administrative matters-Provides leadership in the use of evidence-based medicine in clinical care-Provides Plans with TEC Assessments and the Medical Policy ReferenceManual (MPRM)-The Medical Policy Panel presents monthly reviews of policy draftsfollowed by discussion and vote by members from all Plans-Plans may adopt these policies or utilize them to reach their owndecisions on matters of coverage or utilization management
39 BCNEPA MEDICAL POLICY STATEMENTS EXPERIMENTAL / INVESTIGATIONAL-The technology must have final approval from the appropriate governmental regulatorybodies;-The scientific evidence must permit conclusions concerning the effect of the technologyon health outcomes;-The technology must improve the net health outcome;-The technology must be as beneficial as any established alternatives; and-The improvement must be attainable outside the investigational settings
40 BCNEPA Medical Policies and Utilization Management Clinical Guidelines -Evidence- Based Internally Developed Criteria- Based upon BCNEPA Medical Policy, approved by PatientCare Management Committee-Interqual Criteria- evidence-based, nationally recognized-All services must be medically necessary or they will not be covered-In order for a service to be considered medically necessary, it must be established as safe, effective andprovided in the most appropriate setting-Specifically, the requested services must be:-Appropriate for the symptoms and diagnosis or treatment of the condition, illness, disease orinjury;-Provided for the diagnosis, or the direct care and treatment of the condition, illness, disease or-In accordance with current standards of medical practice (i.e., not experimental or investigational);-Not primarily for the convenience of the member or the provider; and-The most appropriate source or level of service that can safely be provided to the member beingtreated.
41 BCNEPA Medical Policies and Utilization Management Clinical Guidelines BCNEPA Medical Policies and Utilization Management Guidelines are web-based and accessible to providers-BCNEPA.com-Providers Tab – Enter Provider Homepage-Providers Resources & Tools-Medical Policies-Provider Bulletin – Monthly updates to Medical Policies andUtilization Management updates
42 Medical Management-Decision Review Process Pre-certification/Prior Authorization/Preservice Review-A review of medical information prior to provision of healthcareservices to determine if the care and setting are medicallyappropriate according to established criteria/guidelines.Concurrent Review-Review of services during ongoing patient care to determine ifthese services, member symptoms and treatment plans continueto meet guidelines for that level of care.Retrospective Review-A review of medical information that occurs after services arerendered, to ensure clinical appropriateness of services andaccurate application of benefits
43 Medical Management-Decision Review Process -Medical Necessity Claims review-Performed after services rendered, prior to claims adjudication-Please comply with medical records requests-Retrospective Precertification Reviews and Provider Appeals-Considered only if requested no more than 5 business days afterservice-Claims for services provided without an authorization will be deniedand member will not be held liable-Claims rejected for no precertification are provider appeals-Send the appeal request and all supporting documentation to the Complaint,Appeal and Grievance Department
44 Medical Management- Services Reviewed - Inpatient hospital admissions- Inpatient rehabilitation, SNF, LTAC admissions- Behavioral Health (PerformCare)- Pharmaceuticals (ESI)- Home health services- Select outpatient imaging/radiology services (NIA)- Non-participating provider services (HMO)- High cost drugs and non-formulary requests- Select outpatient services- Potential benefit exclusions (i.e. cosmetic, experimental)
45 BCNEPA Medical Management Requirements BCNEPA Prior Authorization/Precertification Requirements are web-based and accessible to providersDetermined by line of Business (First Priority Health, First Priority Life)-BCNEPA.com-Providers Tab – Enter Provider Homepage-Providers Resources & Tools-Reference Material-General Documents-FPH Prior Authorization Requirements or-FPLIC Precertification Requirements
46 BCNEPA Medical Management Requirements When Submitting Prior Authorization or Precertification Requests:Include an admitting diagnosis and a principal/primary diagnosisSubmit requests for transition of care from acute setting to an alternatelevel of care as soon as possible after the transition is planned-Requests for an alternate level of care received late in the day may not beaddressed until the next day-Due to limited SNF availability at times, UM will work to accommodatethese transitions as quickly as possible-Requests should contain all required information – forms are available atProvider Center – Reference Materials – Forms – Medical ManagementForms
48 Transition of Care Coordination -Begins with UM Discharge Care Coordination-The assessment of discharge needs begins with the initial admission authorization-Anticipates post hospital services that may be needed-Ensures optimal transition of care, recovery and contributions toward prevention of readmission-Transition of Care (TOC) program was created in collaboration with AllOne, Pharmacy services and CBHNP(PerformCare).-Purpose: to identify members at risk for readmission or complication during UM discharge planning-Per specific criteria, these members will be referred to the TOC coordinator in UM-The TOC coordinator reaches out to the member within 2 business days of discharge ( 1 day is ourGOLD standard) to ensure-Medication reconciliation-Services ordered have been received-Scheduling of follow up appointment-Barriers to receiving appropriate care-Intervenes quickly to close care gaps-Refers members as appropriate to medical or behavioral case/disease management-Refers members with med questions to Pharmacy Department
49 Medical Management Changes 2014 - CPAP precertification - 1/1/14- UPPP - 1/1/14- Reduction Mammaplasty (when benefit available) – 1/1/14- Implement Regional Strategy- Implement Transition of Care Program
52 What is ICD 10?ICD 10 is the updated version of codes used for coding:-Diagnosis for all providers (ICD 10 CM)-Inpatient hospital procedures (ICD 10 PCS)CPT and HCPCS codes are not affectedby the ICD 10 transition.Compliance date is October 1, 2014Note
53 Why change to ICD 10? ICD 9 has limitations: -Outdated terminology and inconsistency with currentmedical practice-No room for new codes-Lacks specificity and detail-Limits the ability to account for severity
54 Impacted areasICD 10 Implementation affects a wide range of business areas:-Physicians-Hospitals-Payers-IT-Anyone who used ICD 9 codes
55 ICD 10 Changes -Increase in the number of codes CM- 13,000 to 68,000 PCS- 3,000 to 87,000-CM and PCS Character format changefrom 3-5 to 3-7 characters
56 ICD 10 Changes CLINICAL DOCUMENTATION ICD 10 will require more specific information for coders to be able to code.Example: Fractures-Site-Laterality-Type-LocationICD 10 CODE EXAMPLESS Displaced trimalleolar fracture of right lower legS Displaced pilon fracture of right tibia
57 Some tips on preparing for ICD 10 -Establish a ICD 10 transition team or coordinator-Develop a transition plan-Determine the impact on your practice/organization-Review ICD 10 affect on clinical documentation and electronic health records-Communicate with your practice management system, vendors, billers-Tips on talking with your vendors:
58 How will ICD 10 affect your practice? Some questions to help think of the impact to your practice:-Where do you use ICD 9 codes? Make a list of all the places you use ICD 9. Thiswill help identify if you need to change forms such as superbill.-If you use electronic systems, will they accommodate the ICD 10 codes? Checkwith your practice management, system or software vendor to make sure yoursystem will accommodate ICD 10 codes.-Are there ways to make coding more efficient? Develop a list of the mostcommonly used codes and become familiar with the ICD 10 codes.Communicate with your practice management, system or software vendor to assist with ICD 10 transition.
59 Resource What’s Up Wednesday? -4 Blue plan collaboration series of webinars for providers-Information available each month in the provider bulletin or on NEPA website https://www.bcnepa.com/Privacy/HIPAA/ICD-10.aspx-Call InformationBefore the call, visit the BCNEPA ICD-10 website at to access the presentation.Then dial and enter pass code when prompted.Be sure to dial in a few minutes early.
66 BCNEPA NaviNet Prior Authorization Mandate BCNEPA continues to devote additional resources to enhance our NaviNet capabilities for providers, as NaviNet is the preferred source of communication between BCNEPA and our Provider networks.-BCNEPA Prior Authorization Mandate: To further utilize our BCNEPANaviNet capabilities, BCNEPA now requires that all First PriorityHealth (FPH) and First Priority Life Insurance Company (FPLIC) priorauthorization submissions must be submitted through BCNEPANaviNet.REMINDER: BCNEPA Customer Service ‘Do not Call’ initiative - requires providers to use BCNEPA NaviNet for all routine eligibility and benefits questions.
67 BCNEPA NaviNet Prior Authorization Mandate To ensure compliance, BCNEPA will prioritize prior auth requests submitted via NaviNet over requests submitted via fax or phone.Steps for Compliance:-Confirm your office is BCNEPA NaviNet-enabled-Ensure NaviNet access is granted to all pertinent offices/locations(Provider’s security officer is able to grant “user” access)-Obtain additional NaviNet training on Prior Authorization transactionsif needed (Contact your Provider Relations Consultant to schedule atraining session)
68 BCNEPA NaviNet Enhancements effective January 1, 2014 UB04 Claim Submission updatesHeader page:11 additional fields for E-codes and the corresponding Present on Admission (POA) indicatorsDiagnostic Related Group (DRG) field now OptionalDetail page:Added field for ‘Service To Date’
69 BCNEPA NaviNet Enhancements effective January 1, 2014 Eligibility and Benefits Inquiry updates:Added ‘Paid to Date’ with hover over text – ‘Paid to date – The day, month and year through which the policy is paid.’Added NIA indicator box ‘Yes’ or ‘No’ based on member contract
70 BCBSA Electronic Provider Access (EPA) Mandate Effective 1/1/14The Blue Cross and Blue Shield Plans are launching a new tool on January 1, 2014 that will give providers the ability to access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review.EPA will enable providers to use their local Blue Plan provider portal to gain access to an out-of-area member’s Home Plan provider portal, through a secure routing mechanism.Once in the Home Plan provider portal, the out-of-area provider will have the same access to electronic pre-service review capabilities as the Home Plan’s local providers.
71 BCBSA Electronic Provider Access (EPA) Mandate Effective 1/1/14Using the EPA Tool:The first step for providers is to go to BCNEPA NaviNet and log-in as you do today. You will then select the menu option: “Pre-Service Review for Out-of-Area Members (includes notification, pre-certification, pre-authorization and prior approval).Next, you will be asked to enter the alpha prefix from the member’s ID card. The alpha prefix is the first three alpha characters that precede the member id.
72 BCBSA Electronic Provider Access (EPA) Mandate Effective 1/1/14Using the EPA Tool:Entering the member’s alpha prefix from the ID card will automatically route you to the Home Plan EPA landing page. This page will welcome you to the Home Plan portal and indicate that you have left BCNEPA NaviNet. The landing page will allow you to connect to the available electronic pre-service review processesThe Home Plan landing page will look similar across Home Plans, but will be customized to the particular Home Plan based on the electronic pre-service review services they offer.
73 BCBSA Electronic Provider Access (EPA) Mandate Effective 1/1/14Using the EPA Tool:Given that Home Plans are in various states of implementation, not all routes will result in a completed pre-service review. You may see the following messages:BCBS of XXXXX does not currently offer electronic pre-service review. Please callXXX-XXX-XXXX to conduct pre-service review.BCBS of XXXXX does not allow non-Blue providers to access its providerportal. Please call XXX-XXX-XXXX to conduct pre-service review.Alpha prefix is invalid format.Electronic Provider Access for pre-service review does not support FEP.Alpha prefix not found. Please call BLUE for routing to appropriateHome Plan for telephonic pre-service review.Alpha prefix does not exist.Please check our Provider Bulletin and for additional information on the BCBSA EPA Mandate.
74 BCNEPA NaviNet Reminders -ICD-9 and ICD-10 Code Search:-Providers have the ability to search for ICD-9 and ICD-10 (starting Oct2014) procedure and diagnosis codes.-Routine Claims and E&B inquiries:-Providers are reminded to utilize NaviNet for all routine claims and E&Binquiries rather than contact BCNEPA Customer Service-Provider Changes:-Providers should review their NaviNet provider “dropdowns” to assureaccuracy. Please contact your Provider Relations Consultant with anychanges.
76 NEPA’s Patient Review of Provider System (PRP): A Trusted Source of Reviews Blue Cross of Northeastern PennsylvaniaDecember 11, 2013
77 Validated Reviews via BCNEPA.COM Member Interaction with Provider Review Systems:Validated Reviews via BCNEPA.COMValidated- patients need a member ID and need to sign into the system. Patient actually saw you.The NEPA reviews are 100% validated. This means you can be sure that the reviews left are for patients you have seen. The member must use their member ID to log into the system and certify that they have seen you. Comment Moderation exists to ensure we are posting comments that are fair to the provider. All comments go through a restricted terms filter and then on to comment moderation.
78 NEPA PRP System: Ratings and Review Below are the five required Ratings Questions along with the optional Comment Review members have the opportunity to complete:Experience- How would you rate your overall experience and satisfaction with this doctor?Recommend- Would you recommend this doctor to your friend/family?Communication- How well did this doctor communicate with you about your health concerns?Availability- How would you rate the doctor’s availability for your appointment?Environment- How would you rate this doctor’s overall practice environmentComment- Have additional comments to make about this doctor? (free form text box)Checks and balances to protect the providerPatients are limited to review a provider once in every 7 daysCertain words are identified to trigger an action when found in the Member reviewSome words (profanity, ethnic slurs) immediately invalidate the user comment.For other defined terms, review is flagged and placed in moderation queueModerator can then decide to approve or reject the review, based on Plan’s business rulesThis is a customizable featurePlan has option of having all flagged reviews analyzed by employees or having automated system
79 NEPA PRP SystemDesigned for maximum consumer engagement and response. Simple, easy and fast to use.Single sign-on for member – Reviews by Patients NO Anonymous Reviews or RatingsThree-Tiered Moderation Protocols built inRestricted Terms Automated Filter (e.g. Profanity, inappropriate/offensive Content)Reviews that pass Tier 1 are reviewed by human moderator (e.g. Abusive Content, Security, General Troublemaking, Allegations of Illegal Activity, Redundant Reviews)Escalated or Flagged Reviews Delivered to NEPA (e.g. Removal of Reviews, General Research, Conflict Resolution)Checks and balances to protect the providerPatients are limited to review a provider once in every 7 daysCertain words are identified to trigger an action when found in the Member reviewSome words (profanity, ethnic slurs) immediately invalidate the user comment.For other defined terms, review is flagged and placed in moderation queueModerator can then decide to approve or reject the review, based on Plan’s business rulesThis is a customizable featurePlan has option of having all flagged reviews analyzed by employees or having automated system
81 Lots of Options: Where Does NEPA fit? Millions of individual consumers search for rating systems to guide their decision makingOpportunity: “Healthcare ratings are still in a formative stage” (National Committee for Quality Assurance)NEPA PRP: Where validated reviews by actual patients belongVitals believes that reviews and information to guide the patient in decision making should come from the health plan therefore we only work with healthplans, not employers. We have used our consumer background to inform our processes on the health plan side.Consumers are searching ratings to help guide them.NEPA is validated by actual patients. Huge opportunity for NEPA and patients.Source: Angie’s list:52% of people say they would be likely to use websites that offer quality rankings, satisfaction ratings and patient reviews for specific doctors and hospitals17% have consulted online reviews or rankings about providers while only4% have reviewed a provider30% of online e-commerce daily deals are health related
82 Increasing Patient Review Quantities Ask patients to go to BCNEPA.COM to leave a reviewFront office / Back office verbal or written requestsPiggyback on Existing Outbound campaigns to stimulate reviews (e.g. appointment confirmation, marketing, ‘time to make appointment’ reminder)Use of in-practice kiosks to allow patients to leave reviews on reliable sites such as BCNEPA.comOn hold messagingIn addition, Vitals is working with NEPA on a few campaigns that would recognize top docs as submitted by member reviews. Not only will this provide recognition to the top providers, but also alert members to how they can go on line and rate their physician.Ongoing heuristic testing to increase responsePlace survey access on Doc Finder, EOB and other member Touch PointsPlace survey access on claims listings, “My BCBS” pagesOutbound s (or on claims ) to stimulate reviewsAlert s on Provider changes“Please Review” ads and blurbs across the Plan websiteEngaging Providers to encourage active review behaviorReviews per Patient Website Visit: 1.05% responseIncreases by 74% to 1.84% with another prior review on ProviderIncreases by ~20% with a Provider Photo47% of Reviewers leave prose commentsForcing a prose comment mostly reduces overall responsiveness, rather than increasing the # of prose comments“Natural” Completion rate for those who access survey: 31%Pop-up abandon boxes can slightly increase completion rate
83 Thank You! Joy Tu / Account Director / email@example.com Meghan Marazas / Sales Director /83
86 How is Product Development Changing Under the ACA? Major changes impacting health insurance product design and rating under the Affordable Care Act (ACA)Covering Pre-existing Conditions/Guaranteed IssueMandating Broader BenefitsStandardizing rating practicesCovering the UninsuredAccessing Coverage – Exchange/MarketplaceProviding Financial Assistance
88 How Do BCNEPA Policies Look—Metal Levels The FFM Exchange and the BlueCrossNEPAStore.com display plans according to a metal level: This is intended to help shoppers better understand the coverage a plan offersPlatinum plans are best for those who expect to use a lot of health care services-Insurance Plan will cover, on average, 90% of medical care costs.Gold plans are best for those who want to save on premiums while keeping your out-of-pocket costs low-Insurance Plan will cover, on average, 80% of medical care costs.Silver plans are best for those who want to balance your monthly premium with your out-of-pocket costs and for those eligible for Cost Share Subsidies-Insurance Plan will cover, on average, 70% of medical care costs.Bronze plans are best for those who don’t expect to need a lot of health care services-Insurance Plan will cover, on average, 60% of medical care costs.
89 Providing Financial Assistance Through the FFM -Substantial financial assistance to make coverage more affordable for lowand moderate incomes-Premium tax credits for certain income levels:up to 400% FPL (approx. $46,000/individual or $94,000/family of four)-Tax credit decreases as income rises-Assistance with out-of-pocket medical expenses-About 60% of current individual market purchasers will be eligible forsubsidies-90 day Grace period regulation applies only to those members who areeligible for Premium Tax Credits and Cost Sharing Subsidies-BCNEPA pays for claims for services rendered in the first 30 days of the grace period-Clams for services rendered between day 31 and 90 will be pended until premium isreceived-If premium is not paid by the 90th day, pended claims will be denied-Paid to Date Status will display on Navinet
90 Providing Financial Assistance - How do the premium tax credits work?-Must purchase insurance through Federally Facilitated Marketplace (FFM)-FFM will conduct the calculation-Reduces the monthly premium amount –OR— applies to tax filing to reduce taxbill or increase refund- How much is the tax credit worth?FPLIncome (Family of 4)Max Credit value%$23,550-$31,322Pays no more than 2% of annual income on premium%$31,323-$35,090No more than 3%150%$35,325No more than 4%200%$47,100No more than 6.3%250%$58,875No more than 8.05%%$70,650-$94,200No more than 9.5%Sliding scale based on incomeBased on the cost of the health insurance policy:individuals will only pay up to a certain amount for their premiums, remainder subsidized by tax credit
91 Providing Financial Assistance - How do the cost share subsidies work?-Additional cost-sharing subsidies are available for individuals whose householdincomes are under 250% of the Federal Poverty Level (FPL)American Indians receive 100% subsidy up to 300% of the FPL and 100% on certain services between 300% and 400% of the FPL-Available only on a Silver Plan in the FFM (any level for American Indians)- Who qualifies for cost sharing subsidiesAll Americans including American Indians (A.I.)All AmericansExcluding A. I.American IndiansFPLQualifying Percentage100%150%200%250%300%350%400%2016 FPL income levelsSingle$11,800$17,600$23,600$29,400+$29,400$35,400$41,200$46,800Family of 4$24,000$36,000$48,000$60,000+$60,000$72,000$84,000$96,200Subsidy LevelCost Sharing Percentage94% Silver ActuarialValue87% Silver Actuarial73% Silver Actuarial70% Silver ActuarialAny Metal levelAny metal Level100% Selected Service Providers
95 Small Group Products-Products offered to small group employers beginning 1/1/2014:-BlueCare PPO (SHOP and off-exchange)-BlueCare Custom PPO (off-exchange)-BlueCare QHD PPO (off-exchange)-AffordaBlue (off-exchange)-Plans are required to meet the ACA requirements for Essential HealthBenefit Plans (Platinum, Gold, Silver and Bronze)-Total out-of-pocket maximum of $6350 includes both medical and Rx-Maximum of $2000 deductible for in-network benefits-Offering limited SHOP Plans in 2014
96 Large Group Products-Products offered to large group employers must adhere to limited aspects of theACA in 2014-Total Maximum Out of Pocket applies to medical only-Rx integration delayed until January 1, 2015-Minimum Essential Coverage (virtually any plan in existence today) and MinimumValue Coverage (Actuarial Value must be at least 60%)-If coverage fails, penalty accessed in 2015 will be $3000 per employee whoenrolls through the FFM and qualifies for FFM subsidies-If no coverage is offered, the penalty accessed in 2015 will be $2000 foreach full time employee less the first 30-All products are offered to large groups: Custom PPO, PPO, HMO, AffordaBlue,Qualified High Deductible PPO, Qualified High Deductible Custom PPO and EPO
98 Healthcare reform / ACA General updates Michael YantisDirector, Policy ManagementThis presentation is not intended to be a comprehensive review of the content of the legislation, nor should it be interpreted as authoritative and/or legal advice on implementation. The presentation represents our best understanding as of the date of the presentation. In the event you have questions applicable to your business, employees, customers or constituents, we recommend you request the advice of competent legal counsel.
99 AgendaWhat was it?What is it?What does it mean?
101 How Health Insurance was to Change Covering Pre-existing Conditions/Guaranteed IssueMandating Essential Health BenefitsStandardizing rating practicesCovering the UninsuredAccessing Coverage – Exchange/MarketplaceProviding Financial AssistanceNew TaxesThere are SEVEN major changes to health insurance under the Affordable Care Act (ACA)
102 Affordable Care Act Timeline—as it used to be Since the enactment of the ACA in March of 2010, many of the law’s provisions have already been put in place, but the most transformational aspects of Health Care Reform will take effect in 2014.3/10: ACA signed into lawPre-Existing Condition Insurance Plan–a national high-risk pool–launchedChildren under 19 may not be excluded for pre-existing conditionsDependent coverage to age 26Limits on rescissionsNo lifetime limitsNo cost sharing on preventive servicesInternal/external appealsEmergency care at in-network cost-sharing levelsGrandfatheringMedical Loss Ratio mandates (80% individual/small group; 85% group)6/12: U.S. Supreme Court upheld lawSummary of Benefits Coverage (SBC)Women’s preventive services with no cost sharingAccountable care OrganizationsState Notification of Intent to operate a state-based exchangeW-2 Reporting of Health BenefitsPatient-Centered Outcomes Research Institute (PCORI) Fee10/13: Open enrollment through exchanges beginsMedicare tax increaseReduced FSA contribution capCO-OP health insurance plans1/14: Coverage purchased through exchanges beginsGuaranteed IssueIndividual mandateHealth insurance premium and cost-sharing subsidiesNo annual limits on coverageEssential Health BenefitsOOP maximum and deductible limitsMinimum actuarial valueTemporary reinsurance programEmployer “play or pay”Health insurer annual taxRating restrictions/ adjusted community rating
103 Accessing Coverage—Exchange/Marketplace What is itWhat it doesA website or portal to facilitate the purchase of health insurance.Provide Customer Service / Calculate individual subsidies, tax credits, and Medicaid and CHIP eligibility / Certify Qualified Health Plans /Assign Ratings to Health Plans.Here to Help:NavigatorsEstablished by the ACATrained to assist consumers apply; establish eligibility; and enroll in coverageFunded through federal grant dollarsCertified CounselorsSimilar to Navigators; no grant fundingAgents and BrokersCan perform existing duties depending on Exchange requirements / reimbursed by issuer or consumer per Exchange requirements
105 Federal ACA Implementation Delays Administration has called a time out on several key provisions:Employee Choice (SHOP Provision)Large (>50 employees) employer mandate – “play or pay”Income verification for subsidies--Self attestationIndividual responsibility (mandate) extension—from Mid-Feb to March 312014 Market Reforms (“Grandmothering” )(no medical underwriting; guaranteed issue; rating restrictions)Functional Exchange on Oct 1, 2013SHOP
106 What Does it Mean-Mix of ACA compliant policies and non-compliant (grandmother andgrandfathered) policies-BCNEPA—Special Care policies will be sold in 2014 as a “grandmothered” policy; allothers following marketplace rules-FFM/Exchange functionality remains a challenge-Nov 30 “deadline:” report is that Exchange/FFM is better than before-Up front experience improved-Backend (connection to insurers) still problematic-Feds developing a work around for subsidies (direct enrollment)-Key upcoming dates:-December 23, 2013—deadline for enrollment for Jan 1, 2014 coverage-March 31, 2014—end of open enrollment-FFM/Exchange and subsidies remain very much in play
107 When the FFM/Exchange is Functional What the policies will look like:PlatinumGoldSilverBronzeMonthly cost$$$$$$$$$$Cost when you get care (cost sharing)10%20%30%40%Good option if you…expect to use a lot of health care serviceswant to save on monthly premiums while keeping your out-of-pocket costs lowneed to balance your monthly premium with your out-of-pocket costsdon’t expect to need a lot of health care services
108 Medicaid and the ACA Background Healthy PA -ACA permits (SCOTUS Ruling) states to expand eligibility for Medicaid up to 133% offederal poverty level-Controversial budget and political issue among several statesHealthy PA-NO to “straight up” expansion-YES to a PA specific approach—”we can do it better”-Draft waiver proposal release in 12/7/2013 PA Bulletin—Medicaid Reform- Traditional MedicaidHigh Risk Alternative Benefit Plan—more complex health care needsLow Risk Benefit Plan—those with lower health risks- Healthy PA Medicaid (AKA, the expansion)Individuals will purchase coverage through FFM, non FFM market, Employer Sponsored InsuranceSame/similar benefits to existing QHP (e.g. EHBs)Same provider network as existing Commercial networksMedically frail eligible for traditional Medicaid- Visit for more detail
109 Some Final Thoughts Grace period Increased demand for services -Individuals enrolled in a QHP AND receiving a premium tax creditreceive a 90-day grace period for non-payment of premiumDays 1-30—health insurers required to continue paying for servicesDays 31-90—health insurers will pend payment for servicesIncreased demand for services-Expectation is that more insured = more demand for service andmore utilizationNew individuals to the world of health insurance and health care payment
110 Federal Marketplace Call Center ResourcesBlue Cross of Northeastern PennsylvaniaHealthCare.govhttps://localhelp.healthcare.gov/Federal Marketplace Call CenterTime for AffordabilityPA Insurance Department
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