Presentation on theme: "Blue Cross and Blue Shield of Kansas Update"— Presentation transcript:
1Blue Cross and Blue Shield of Kansas Update All Payers WorkshopDecember 5, 2014Presented by Sally Stevens
2Kansas Solutions A new BCBSKS subsidiary Effective January 1, 2015 Limited network – BCBSKS' 103-county service area only! Excludes Johnson & Wyandotte Counties in KSRepresented by an empty suitcaseSold to individuals on and off the exchange and small group (SHOP) marketsClaims for Solutions members will have its own remittance advice (RA)
3Kansas Solutions Blue Solutions is not a traditional HMO: Members will NOT choose a Primary Care Provider (PCP)No referral is needed for visiting a specialty providerMembers have open access through the BCBSKS Blue Choice networkProviders reimbursed using Blue Choice payment rates
5Kansas SolutionsThe following alpha prefixes will be used for Kansas Solutions members:XSC - Individual Exchange SolutionsXSG - SHOP Exchange SolutionsXSQ - Individual Solutions Off-ExchangeXSR - Small Group Solutions Off-Exchange
8Affordable Care Act (ACA) Grace Period ACA mandates a three-month grace period for individual members who:receive a premium subsidyhave paid at least one month's premiumare delinquent in paying their portion of premiums
9Affordable Care Act (ACA) Grace Period BCBSKS will:pay the claims with a date of service in the first month of being delinquentpend the claims with a date of service in the second and third month of being delinquentproviders will a receive a letter when claims are pending
10Affordable Care Act (ACA) Grace Period Providers cannot bill the patient during the three-month grace period.Provider can bill the patient once they have received a remittance advice advising the adjudication of the claim.If the patient purchases coverage through the Marketplace again and they meet the ACA grace period mandate, the patient can have coverage again and not have to remit payment for the previous delinquent dues.Availity will display delinquent information for month two and three beginning January 1, 2015.
11ICD-10 Testing Two types of testing: Acknowledgement testing: Healthcare payer confirms that a test claim can be accepted, but doesn't test how it will be reimbursed.End-to-End testing: Healthcare payers will submit a test claim through the payers claim adjudication system and report the reimbursement to the provider.
12ICD-10 TestingAcknowledgement testing is testing with the provider's vendor/clearinghouse etc.; not the payer.ICD-10 test claim is createdTest claim is transmitted to your clearinghouse or ASKFront-end edits, including validation of ICD-10 code set, will be appliedAcknowledgments (999 and 277CA) will be generatedNo test 835 will be returned
13ICD-10 Testing End-to-End testing is testing with the payer Testing begins February 2015Providers need to request set-up in the test systemICD-10 test claim is createdTest claim data is submitted to BCBSKS via a spreadsheetTest claim is transmitted to your clearinghouse or ASKFront-end edits, including validation of ICD-10 code set, will be appliedAcknowledgments (999 and 277CA) will be generatedTest 835 will be returned
14ICD-10 Testing Providers testing could see unexpected rejections Testing benefits you and the payersFinal thoughts on ICD-10 Testing:budget for and expect delaysreview acknowledgements and utilize claim status resources
15Reducing claims is a win for everyone! Corrected ClaimsIncreases administrative expensesSlows down payment turnaroundReasons for filing a corrected claim:billing late charges (lab, physical therapy, drugs, anesthesia, recovery room, Operating Room services)combining outpatient services onto an inpatient claimadd additional diagnosis code or a modifierWork to find ways within your hospital to ensure that all the charges are on the initial claim.Reducing claims is a win for everyone!
16Blue Cross and Blue Shield of Kansas Update Thank you for your time today!Questions?