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Blue Cross of Northeastern Pennsylvania

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1 Blue Cross of Northeastern Pennsylvania
PROVIDER WEBINAR Blue Cross of Northeastern Pennsylvania December 11, 2013

2 Senior Manager, Provider Relations
WELCOME Dave Levenoskie Senior Manager, Provider Relations

Jean Wiernusz Consultant, Provider Relations

4 Health Plan Updates - BCNEPA
General Updates - Community Behavioral Healthcare Network of PA (CBHNP) has changed its name to PerformCare as of 10/1/13 -Annual Provider Satisfaction Survey has been sent. Please complete and return if you haven’t already done so -Remind your patients to get their flu shot. Note: Nasal spray vaccine is only covered 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 to the Department of Health and Human Services -BCBSA has contracted with Verisk Health to provide an efficient, centralized process to coordinate medical record requests from Blue Cross and/or Blue Shield companies across 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 for you to comply with these requests

6 Health Plan Updates - BCNEPA
Suboxone Update FPH/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) are available for FPH, FPLIC and BCNEPA -ERA files are sent to you via your clearing house or NaviNet and your software vendor will provide instruction to download this file to post payments 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/or Provider 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 claim The 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 prior authorization through NIA: emergency room, observation, inpatient and urgent care centers. -It is the responsibility of the ordering physician to obtain authorization. -Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of 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 that emphasize patient safety and outcomes. -Facilities currently designated as BDC must have in-network status. All Hospital Based Physicians and Key Specialists (who are likely to provide services 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 BDCT facility 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 Upper Respiratory Infection (URI) -Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis -LDL-C Screening for Patients with Coronary Artery Disease (CAD) -Diabetes HbA1c test -Diabetes LDL-C Screening -Diabetes Eye Exam -Diabetes Microalbumin Test

21 BCNEPA Reminders Provider Center – Our BCNEPA Provider Center is a great resource for important information and updates. Please check the Provider Center site via NaviNet or for bulletins, manuals, forms, and policies 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 MRI REMINDER: Providers must be privileged by NIA to perform radiology studies 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 added 1 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 File Maintenance” from the Plan Central menu -Remember that new providers may need to be credentialed before they can be added; Contact your BCNEPA Provider Relations Consultant to begin 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 products Simplified Co-payments and Visit Counts effective 9/1/13 -Applies to physical, occupation and speech therapy and spinal manipulation -Only 1 co-payment will be applied per date of service per provider -Only 1 visit will be counted per date of service per provider Note that visit limits are still applicable

27 Health Plan Updates - Highmark
Physical Medicine Management Program Reminders: Two components: Care Registration Care Authorization Reminder: -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 members seen locally will be processed by Highmark as BlueCard claims -DME and P&O Providers should submit claims according to the BlueCard Ancillary Guidelines which are available on the Provider Resource Center -If your claim system is programmed to submit claims for patients with IBC Personal Choice alpha prefixes, you should now direct those claims to 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 used when 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 an October Special Bulletin which may be found on the Provider Resource Center

30 Health Plan Updates – Highmark Medicare Advantage
2014 Medicare Advantage Premiums and Benefits -Premium changes are minimal – monthly increases are less than $10 in most cases -For most members, there are no changes to copayments for visits and prescription drugs -Oxygen and oxygen-related equipment and supplies will be subject to co-insurance effective 1/1/14 -The annual deductible has decreased for the Freedom Blue PPO High Deductible plan and a closed formulary has been added -Members will continue to have access to one of the largest and rapidly growing networks of doctors, hospitals, and other health care providers in the region

31 Health Plan Updates – Highmark Medicare Advantage
Medicare Advantage Medical Policies – Effective 10/14/13 The 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 Radiosurgery Please 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 Update Effective 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 adjustments The Medicare Advantage Fee Schedule will remain unchanged.


34 MEDICAL MANAGEMENT Irene Swartwood Julie Cohen
Supervisor, Medical Policy Julie Cohen Director, Utilization Management

-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

-Identification of technology for assessment based upon needs of customers and clinical importance -Evaluation of new technology and the new applications of existing technology -Utilize BCBSA TEC Assessments to determine clinical effectiveness and appropriateness -Conduct extensive literature searches from regulatory bodies -Review BCBSA’s Medical Policy Reference Manual -Participate in monthly BCBSA Medical Policy Panel discussions and update policies accordingly

- 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 Care Management Committee - Evaluate policies for safety, efficacy, cost-effectiveness, ethical and legal implication

38 Blue Cross Blue Shield Association (BCBSA) Guidance
-A cohesive force that brings 37 independent Plans together in a national system -Serves the common needs of the Plans by making recommendations on 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 Reference Manual (MPRM) -The Medical Policy Panel presents monthly reviews of policy drafts followed by discussion and vote by members from all Plans -Plans may adopt these policies or utilize them to reach their own decisions on matters of coverage or utilization management

EXPERIMENTAL / INVESTIGATIONAL -The technology must have final approval from the appropriate governmental regulatory bodies; -The scientific evidence must permit conclusions concerning the effect of the technology on 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 Patient Care 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 and provided in the most appropriate setting -Specifically, the requested services must be: -Appropriate for the symptoms and diagnosis or treatment of the condition, illness, disease or injury; -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 being treated.

41 BCNEPA Medical Policies and Utilization Management Clinical Guidelines
BCNEPA Medical Policies and Utilization Management Guidelines are web-based and accessible to providers -Providers Tab – Enter Provider Homepage -Providers Resources & Tools -Medical Policies -Provider Bulletin – Monthly updates to Medical Policies and Utilization Management updates

42 Medical Management-Decision Review Process
Pre-certification/Prior Authorization/Preservice Review -A review of medical information prior to provision of healthcare services to determine if the care and setting are medically appropriate according to established criteria/guidelines. Concurrent Review -Review of services during ongoing patient care to determine if these services, member symptoms and treatment plans continue to meet guidelines for that level of care. Retrospective Review -A review of medical information that occurs after services are rendered, to ensure clinical appropriateness of services and accurate 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 after service -Claims for services provided without an authorization will be denied and 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 providers Determined by line of Business (First Priority Health, First Priority Life) -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 diagnosis Submit requests for transition of care from acute setting to an alternate level 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 be addressed until the next day -Due to limited SNF availability at times, UM will work to accommodate these transitions as quickly as possible -Requests should contain all required information – forms are available at Provider Center – Reference Materials – Forms – Medical Management Forms

47 Medical Management Changes 2013
-Transitioned HH, SNF, LTAC, and Acute Rehab reviews to Interqual© Criteria -Increased Auto Authorization list 4/1/13 -Increased Focus PAC review 7/1/13 (FPLIC) -Implemented outpatient precertification requirement for the following: -IMRT, HBO, Bone Growth Stimulation, Spinal Stimulation 6/1/13 -Sleep Studies 8/1/13 -Pre-Transplant Evaluation/Consultation 8/1/13 -Spinal Pain Management (epidural, facet injections, facet joint denervation) 9/1/13 -Implemented consistent concurrent review and discharge planning -Development of a Transition of Care program -Began steps to Regionalize the UM Department into 3 regions -OOA -East – Includes Luzerne, Poconos (includes Lehigh Valley), -West- Includes Lackawanna and western counties

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 our GOLD 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


51 Manager, Clinical Coding Applications
ICD-10 OVERVIEW Pam Ross Manager, Clinical Coding Applications

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 affected by the ICD 10 transition. Compliance date is October 1, 2014 Note

53 Why change to ICD 10? ICD 9 has limitations:
-Outdated terminology and inconsistency with current medical practice -No room for new codes -Lacks specificity and detail -Limits the ability to account for severity

54 Impacted areas ICD 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 change from 3-5 to 3-7 characters

ICD 10 will require more specific information for coders to be able to code. Example: Fractures -Site -Laterality -Type -Location ICD 10 CODE EXAMPLES S Displaced trimalleolar fracture of right lower leg S 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. This will help identify if you need to change forms such as superbill. -If you use electronic systems, will they accommodate the ICD 10 codes? Check with your practice management, system or software vendor to make sure your system will accommodate ICD 10 codes. -Are there ways to make coding more efficient? Develop a list of the most commonly 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 -Call Information Before 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.


61 NEPA’s ICD 10 Preparation
What is NEPA doing to prepare for ICD 10 implementation: - Ensure systems are ICD 10 capable and ready - Medical Policy remediation - Benefit coding conversion

62 NEPA’s ICD 10 Preparation
- Provider Communication - Neutrality - Testing - Employee Training


Becky Krasson Specialist, EDI

65 BCNEPA NaviNet Update -BCNEPA Prior Authorization Mandate
-BCNEPA NaviNet Enhancements -UB04 Claims Submission Changes -Eligibility and Benefits Enhancements -BCBSA Electronic Provider Access Mandate -BCNEPA NaviNet Reminders

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 BCNEPA NaviNet capabilities, BCNEPA now requires that all First Priority Health (FPH) and First Priority Life Insurance Company (FPLIC) prior authorization submissions must be submitted through BCNEPA NaviNet. 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 transactions if needed (Contact your Provider Relations Consultant to schedule a training session)

68 BCNEPA NaviNet Enhancements effective January 1, 2014
UB04 Claim Submission updates Header page: 11 additional fields for E-codes and the corresponding Present on Admission (POA) indicators Diagnostic Related Group (DRG) field now Optional Detail 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 1/1/14 The 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 1/1/14 Using 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 1/1/14 Using 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 processes The 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 1/1/14 Using 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 call XXX-XXX-XXXX to conduct pre-service review. BCBS of XXXXX does not allow non-Blue providers to access its provider portal.  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 appropriate Home 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 Oct 2014) procedure and diagnosis codes. -Routine Claims and E&B inquiries: -Providers are reminded to utilize NaviNet for all routine claims and E&B inquiries rather than contact BCNEPA Customer Service -Provider Changes: -Providers should review their NaviNet provider “dropdowns” to assure accuracy. Please contact your Provider Relations Consultant with any changes.


76 NEPA’s Patient Review of Provider System (PRP): A Trusted Source of Reviews
Blue Cross of Northeastern Pennsylvania December 11, 2013

77 Validated Reviews via BCNEPA.COM
Member Interaction with Provider Review Systems: Validated Reviews via BCNEPA.COM Validated- 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 environment Comment- Have additional comments to make about this doctor? (free form text box) Checks and balances to protect the provider Patients are limited to review a provider once in every 7 days Certain words are identified to trigger an action when found in the Member review Some words (profanity, ethnic slurs) immediately invalidate the user comment. For other defined terms, review is flagged and placed in moderation queue Moderator can then decide to approve or reject the review, based on Plan’s business rules This is a customizable feature Plan has option of having all flagged reviews analyzed by employees or having automated system

79 NEPA PRP System Designed for maximum consumer engagement and response. Simple, easy and fast to use. Single sign-on for member – Reviews by Patients NO Anonymous Reviews or Ratings Three-Tiered Moderation Protocols built in Restricted 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 provider Patients are limited to review a provider once in every 7 days Certain words are identified to trigger an action when found in the Member review Some words (profanity, ethnic slurs) immediately invalidate the user comment. For other defined terms, review is flagged and placed in moderation queue Moderator can then decide to approve or reject the review, based on Plan’s business rules This is a customizable feature Plan has option of having all flagged reviews analyzed by employees or having automated system

80 NEPA’s Patient Reviews for Providers

81 Lots of Options: Where Does NEPA fit?
Millions of individual consumers search for rating systems to guide their decision making Opportunity: “Healthcare ratings are still in a formative stage” (National Committee for Quality Assurance) NEPA PRP: Where validated reviews by actual patients belong Vitals 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 hospitals 17% have consulted online reviews or rankings about providers while only 4% have reviewed a provider 30% of online e-commerce daily deals are health related

82 Increasing Patient Review Quantities
Ask patients to go to BCNEPA.COM to leave a review Front office / Back office verbal or written requests Piggyback 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 On hold messaging In 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 response Place survey access on Doc Finder, EOB and other member Touch Points Place survey access on claims listings, “My BCBS” pages Outbound s (or on claims ) to stimulate reviews Alert s on Provider changes “Please Review” ads and blurbs across the Plan website Engaging Providers to encourage active review behavior Reviews per Patient Website Visit: 1.05% response Increases by 74% to 1.84% with another prior review on Provider Increases by ~20% with a Provider Photo 47% of Reviewers leave prose comments Forcing 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 /
Meghan Marazas / Sales Director / 83


85 BCNEPA ACA Product Overview
Celeste Curley Senior Director, Product Management

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 Issue Mandating Broader Benefits Standardizing rating practices Covering the Uninsured Accessing Coverage – Exchange/Marketplace Providing Financial Assistance

87 Mandating Broader Benefits

88 How Do BCNEPA Policies Look—Metal Levels
The FFM Exchange and the display plans according to a metal level: This is intended to help shoppers better understand the coverage a plan offers Platinum 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 low and 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 for subsidies -90 day Grace period regulation applies only to those members who are eligible 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 is received -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 tax bill or increase refund - How much is the tax credit worth? FPL Income (Family of 4) Max Credit value % $23,550-$31,322 Pays no more than 2% of annual income on premium % $31,323-$35,090 No more than 3% 150% $35,325 No more than 4% 200% $47,100 No more than 6.3% 250% $58,875 No more than 8.05% % $70,650-$94,200 No more than 9.5% Sliding scale based on income Based 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 household incomes 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 subsidies All Americans including American Indians (A.I.) All Americans Excluding A. I. American Indians FPL Qualifying Percentage 100% 150% 200% 250% 300% 350% 400% 2016 FPL income levels Single $11,800 $17,600 $23,600 $29,400+ $29,400 $35,400 $41,200 $46,800 Family of 4 $24,000 $36,000 $48,000 $60,000+ $60,000 $72,000 $84,000 $96,200 Subsidy Level Cost Sharing Percentage 94% Silver Actuarial Value 87% Silver Actuarial 73% Silver Actuarial 70% Silver Actuarial Any Metal level Any metal Level 100% Selected Service Providers

92 BCNEPA Qualified Health Plans

93 BCNEPA Qualified Health Plans

94 BCNEPA Qualified Health Plans

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 Health Benefit 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 the ACA 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 Minimum Value Coverage (Actuarial Value must be at least 60%) -If coverage fails, penalty accessed in 2015 will be $3000 per employee who enrolls through the FFM and qualifies for FFM subsidies -If no coverage is offered, the penalty accessed in 2015 will be $2000 for each 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 Yantis Director, Policy Management This 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 Agenda What was it? What is it? What does it mean?

100 What was Health Care Reform?

101 How Health Insurance was to Change
Covering Pre-existing Conditions/Guaranteed Issue Mandating Essential Health Benefits Standardizing rating practices Covering the Uninsured Accessing Coverage – Exchange/Marketplace Providing Financial Assistance New Taxes There 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 law Pre-Existing Condition Insurance Plan–a national high-risk pool–launched Children under 19 may not be excluded for pre-existing conditions Dependent coverage to age 26 Limits on rescissions No lifetime limits No cost sharing on preventive services Internal/external appeals Emergency care at in-network cost-sharing levels Grandfathering Medical Loss Ratio mandates (80% individual/small group; 85% group) 6/12: U.S. Supreme Court upheld law Summary of Benefits Coverage (SBC) Women’s preventive services with no cost sharing Accountable care Organizations State Notification of Intent to operate a state-based exchange W-2 Reporting of Health Benefits Patient-Centered Outcomes Research Institute (PCORI) Fee 10/13: Open enrollment through exchanges begins Medicare tax increase Reduced FSA contribution cap CO-OP health insurance plans 1/14: Coverage purchased through exchanges begins Guaranteed Issue Individual mandate Health insurance premium and cost-sharing subsidies No annual limits on coverage Essential Health Benefits OOP maximum and deductible limits Minimum actuarial value Temporary reinsurance program Employer “play or pay” Health insurer annual tax Rating restrictions/ adjusted community rating

103 Accessing Coverage—Exchange/Marketplace
What is it What it does A 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: Navigators Established by the ACA Trained to assist consumers apply; establish eligibility; and enroll in coverage Funded through federal grant dollars Certified Counselors Similar to Navigators; no grant funding Agents and Brokers Can perform existing duties depending on Exchange requirements / reimbursed by issuer or consumer per Exchange requirements

104 What it is now…

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 attestation Individual responsibility (mandate) extension—from Mid-Feb to March 31 2014 Market Reforms (“Grandmothering” )(no medical underwriting; guaranteed issue; rating restrictions) Functional Exchange on Oct 1, 2013 SHOP

106 What Does it Mean -Mix of ACA compliant policies and non-compliant (grandmother and grandfathered) policies -BCNEPA—Special Care policies will be sold in 2014 as a “grandmothered” policy; all others 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: Platinum Gold Silver Bronze Monthly cost $$$$ $$$ $$ $ Cost when you get care (cost sharing) 10% 20% 30% 40% Good option if you… expect to use a lot of health care services want to save on monthly premiums while keeping your out-of-pocket costs low need to balance your monthly premium with your out-of-pocket costs don’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% of federal poverty level -Controversial budget and political issue among several states Healthy 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 Medicaid High Risk Alternative Benefit Plan—more complex health care needs Low 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 Insurance Same/similar benefits to existing QHP (e.g. EHBs) Same provider network as existing Commercial networks Medically 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 credit receive a 90-day grace period for non-payment of premium Days 1-30—health insurers required to continue paying for services Days 31-90—health insurers will pend payment for services Increased demand for services -Expectation is that more insured = more demand for service and more utilization New individuals to the world of health insurance and health care payment

110 Federal Marketplace Call Center
Resources Blue Cross of Northeastern Pennsylvania Federal Marketplace Call Center Time for Affordability PA Insurance Department


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