Presentation on theme: "Anthem MSMA Presentation"— Presentation transcript:
1 Anthem MSMA Presentation April 2014This presentation contains proprietary information of Anthem Blue Cross and Blue Shield.Any redistribution or other use is strictly prohibited.
2 Objectives Anthem MO Provider Networks Anthem MO Products Member ID CardsBlueCardNew Exchange Levels/Products/CardsClaims Filing GuidelinesAddressesClaim Escalation Process/Network ManagementOnline Self Service ToolsQuestion & Answer
6 Member ID CardsMembers Identification Number- Member identification numbers are found on the identification card under the member's name. The identification numbers contain three letter prefixes which are critical in the routing and processing of your claim.Network - Knowing the member’s network will assist you in identifying the applicable reimbursement schedule. You need to have this information when registering members in your office.
7 Member ID Cards Steps to determine reimbursement schedule: First look for Blue Access, Blue Access Choice, Blue Preferred or Pathway network on the members id card.If you do not locate Blue Access, Blue Access Choice, Blue Preferred or Pathway network on the id card then look at the suitcase.If the suitcase is empty or you do not locate a suitcase please contact the number on the back of the id card, as the member may not have out of network benefits.Please remember: The suitcase identifies members with benefits when they travel. If a member receives services outside of Anthem’s service area, that member would need to access a provider in that Blue plan’s network to receive in-network benefit levels.(Example)-An Anthem member travels to Kansas and needs to see a Kansas provider. If the suitcase had a PPO then the patient would need to seek out a PPO provider in the Kansas plan to receive their maximum benefit.
10 Blue CardThe Blue Cross and Blue Shield Association (BCBSA) is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies.BlueCard® launched in This program enables member who are traveling or living in another Plan's service area to receive the same healthcare service benefits of their home Plan.
11 What is BlueCard?The BlueCard® Program links health care providers and the independent Blue Cross and Blue Shield Plans across the country and around the world through a single electronic network for claims processing reimbursement.Your local Blue Plan is your single point of contact for claims
13 Examine Insurance ID Card Logos BlueCross BlueShieldof AnywhereAn Independent licensee of theBlue Cross and Blue Shield AssociationDOE, JOHNXYZIdentification No.123456Logos are also important to look for on a card. The most important logo is the “PPO in a suitcase” logo.This indicates the patient has BlueCard PPO. The suitcase logo tells the provider that the patient needs to see a PPO provider not only at home but also when traveling out of his/her Blue Plan’s area to receive maximum in-network benefits.Group No.BS Plan Code BC Plan Code 1210000Sect.
14 BlueCard: Verifying Eligibility and Benefits Ask members for their current member ID cardCheck eligibility and benefits through Availity or by calling BlueCard Eligibility line BLUE (2583)Verify the member’s cost sharing amount (copay) before processing payment
15 Submitting BlueCard® Claims (cont’d) BlueCard ExclusionsFEPMedicare RiskStand-alone dental and prescription drugsVision and hearingBlueCard exclusions are programs that were never intended to run through BlueCard. As a general rule, if there is no alpha prefix do not submit through BlueCard. Look on the back of the card for claims filing information.
17 New Provider NetworkProvider Network For Individual Business ON Exchange: Pathway X Provider Network For Individual Business OFF Exchange: Pathway Same providers for both Individual business ON and OFF Exchange A Focused Network of professional and facility providersThe Pathway and Pathway X Networks both pay off of the Blue Preferred fee schedule.
18 Missouri Metal Level Plans On and Off Exchange ON EXCHANGEOFF EXCHANGEBronze (60% AV)6 Plans including one plan with embedded pediatric dentalSilver (70% AV)4 PlansGold (80% AV)2 Plans including one plan with embedded pediatric dentalCore (60% AV)Essential (70% AV)Preferred (80% AV)This illustration shows our On/Off Exchange products side by side.* Same benefits, but different names.Six Bronze/Core plansFour Silver/EssentialTwo Gold/PreferredAnthem has chosen not to offer Platnum Level plans.The percentage applies to Actuarial Value.Actuarial value (AV): the percent of total allowed cost of benefits paid by a health plan. Also referred to as the “metal levels” – bronze (60% AV), silver (70% AV), gold (80% AV) and platinum (90% AV). Note: there is a plus or minus buffer range for each level of two percent (+/- 2%), referred to as de minimis variation, so, for example, a plan with an actuarial value between 68% and 72% would be considered “silver.”o “Percent of total allowed cost of benefits:” the anticipated covered medical spending for EHB coverage paid by a health plan; factors in the health plan’s cost sharing and divides the cost sharing amount by the total anticipated allowed charges for EHB coverage. The final number is expressed as a percentage
19 Anthem Small Group Products - MO Small Group - On-ExchangeNetwork Name – Blue PreferredProduct TypePrefixAnthem Bronze Direct AccessPPOJWUAnthem Silver Direct AccessAnthem Gold Direct AccessSmall Group – Off-ExchangeNetwork Name – Blue Access, Blue Access Choice, or Blue PreferredProduct TypePrefixAnthem Core Direct AccessPPOYCB, YCA, YCC, YCD, YCEAnthem Essential Direct AccessAnthem Preferred Direct Access
20 Anthem Individual Products Missouri Individual - On-ExchangeNetwork Name - Pathway XProduct TypePrefixAnthem Bronze Direct AccessPPOJWZ, YCHAnthem Silver Direct AccessAnthem Gold Direct AccessIndividual – Off-ExchangeNetwork Name - PathwayProduct TypePrefixAnthem Core Direct AccessPPOJWYAnthem Essential Direct AccessAnthem Preferred Direct AccessThere are also additional updates coming out soon with additional information on the prefixes and ID cards. Watch out for Rapid Updates.If you have not registered for Rapid Updates, you can go to Anthem.com, select Provider and register to receive Rapid Updates. Also there is a tab available on the provider home page with additional information on the Healthcare Exchange.
21 What Does the ID Card Look Like? Missouri Medical Off Exchange - IndividualIn this example for an Off Exchange – Individual membership, you can see the Anthem Blue Cross Blue Shield logo in the upper left hand corner like our other ID Cords, the product is listed in the upper right hand corner, in this example Anthem Core Direct Access, the subscriber name and ID number with the alpha prefix. And the deductibles and coinsurance information. And the Network is located in the lower right hand corner (Pathway) and the PPO in the suitcase which refers to the out of state benefits for urgent and emergency care.We were experiencing some issues in January and early February where the member ID cards that could be printed online did not have all of the essential information on the card. This problem has been corrected and the temporary and permanent cards should contain all of the necessary information. If you do have someone present one of these cards, please ask them to provide you with the card that has been mailed to them or to reprint a current version of their ID card.
22 What Does the ID Card Look Like? Missouri Medical On Exchange - IndividualPlease note the Anthem logo in the upper left hand corner, the product name in the upper right hand corner. In this example, the product is Anthem Silver Direct Access, the members name and identification number with alpha prefix, the copays and deductibles are available and the Network name (Pathway X) is located on the bottom right hand side of the ID card. Also please not the PPO in the suitcase with the B. The B stands for Basic and these are members that have applied for benefits through the exchange and have received subsidies or exemptions. These are the only members that are eligible for the 90 day grace period that we will be covering a little later in the presentation.
23 What is the 90-Day Grace Period? Individual members who purchase their health plan on the marketplace are eligible for a premium subsidy from the government. The ACA mandates a three month grace period for delinquent premium payments.It applies after the individual has paid at least one month of premium within the benefit year.
24 How will the 90-Day Grace Period be implemented? Anthem will process claims for services received during the first monthProviders notified of grace period on remittance for services rendered during second and third month.During the second and third months, if payment is not received, the health plan will be terminated, claims for services received during the second and third month will be denied.Payment made for dates of service within the first month will not be retractedImpacted claims will be automatically adjusted once a member pays their premium, or is terminated (after the end of the grace period).
26 Claims Filing Guidelines File claims within 180 day from the date the services were rendered or date of other carriers EOB. ***Unless your contracts specifies something else.***Use appropriate claim processing forms and CMS billing codesClaims form must have all fields completed.File claims electronicallyFile claims to your local BluePlan
30 Escalation Process Provider Service – Telephone Inquiries In an effort to better serve Providers, we have initiated an escalation process to assist with claim/issue resolution more quickly and efficiently. It is critical to document the reference numbers given on both telephone contacts and secured messaging.Provider Service – Telephone InquiriesWe ask that you contact Provider Service initially. In the event that your claim/issue is not handled to your satisfaction, we ask that you ask for a supervisor. If the rep is sending your claim for adjustment or additional research, we ask that you allow 30 days for resolution. If after the 30 day period, your claim/issue is still unresolved, we ask that you call and request to speak to a supervisor.
31 Escalation Process (cont.) Secured Messaging (Currently in review)If you send a secured message and do not receive satisfactory response, please reply to the original secured message and request that the inquiry be escalated to a supervisor. Please include your name and a number where you can be reached.In both scenarios, once you have escalated your claim/issue please allow 30 days for research/adjustment.If you still require additional assistance after exhausting these avenues, please contact your Network Consultant and provide both reference numbers or secured message transaction number.In order for this procedure to work, please always allow the front end reps the opportunity to resolve your issue first.
32 Improving the Provider Experience: Provider Escalation process (continued) Network Management continues to support questions related to:your provider contractfee schedule discrepancyinformation about how to register and access Anthem’s self-service toolstraining and educationclarification of products or programs offered by Anthem
34 Online Tools Sites to use for Anthem business: web portalMyAnthem----secured web portalportal
35 Self-Service Tools Electronic Data Interchange (EDI) With EDI you can submit and receive transactions from your computer system.Connect directly to Anthem using vendor software or through an approved clearing house.Transactions Available through EDI:Claims submissionElectronic Remittance AdviceElectronic Funds TransferEligibilityBenefitsClaims Status
36 Self Service Tools Interactive Voice Reponses (IVR) Phone access to real-time:EligibilityBenefitsClaims statusUse for one or multiple membersListen to the information or have it sent via faxFEP claims detail
37 Self Service Tools – ICR (Interactive Care Reviewer) Our new online tool offers a streamlined precertification process using cutting-edge IBM Watson technology and can be accessed via Availity to request inpatient and outpatient procedures for many members covered by Anthem and BlueCard plans. Some benefits are:Reduces the need to faxNo additional costAccess almost anywhereComprehensive view of UM requestsEasy access via Availity (Your PAA can grant you access to Authorizations and you can start right away)
38 Interactive Care Reviewer (cont.) Additional webinar training is available to learn more about the features and benefits. Go to:https://www144.livemeeting.com/lrs/ / Registration.aspx?pageName=83vbvn5cvr00ngx4Future planned enhancements include:Expand the use to incorporate behavioral health and additional procedures.
39 Self Service Tools E-Review Secured tool that can be used for Inpatient, Outpatient precertification and predetermination for local Anthem members.Imaging and Specialty Rx-Web ToolsReal time preauthorization's for Radiology, Echocardiography, Radiation Oncology, Specialty Pharmacy, Sleep Study.Medical Policy and Preauthorization Routing ToolThis tool will allow providers to access the medical policies and preauthorization information for other blue plans.BlueCard members –out-of-area members
40 Steps to access the routing tool. Step 1: Locate the blue Medical Policy, Clinical UM Guidelines and Pre-Cert Requirements box on the left side of the page and click “Enter”.
41 Steps to access the routing tool. Step 2: Click on the appropriate link to access the information that is needed.The first two links are for local Anthem members. The bottom two links are for BlueCard out-of area members.
42 How to use the tool.Step 3: Select the type of information requested, enter the first three letters of member’s identification number located on the ID card in the alpha prefix box and click “GO”.
43 How to use the tool.Step 4: Review the disclaimer stating that the user will be leaving Anthem’s site and being directed to an external site not affiliated with Anthem and click “Continue”. This disclaimer will only appear for BlueCard inquiries.
44 It Worked!It worked! The user has been routed to Blue Cross Blue Shield of Illinois’s Medical Policy web pageHere the user can view all medical policies for BCBSIL.Please note that most Blue plans have search function capability that will allow the user to search for a specific procedure by name or code.
45 Self Service Tools Secure Messaging Online secure messaging tool used to contact the PSU regarding a claimLocal claim, BlueCard, FEPCommunicationsE-UpdatesNetwork NewsProvider Maintenance Form (Under the Tab)Electronic Form Required to Begin the Credentialing ProcessAdd/Delete Providers or ProductsMake Any Demographic Changes (Address, Phone, , Fax)
46 Self Service Tools Additional Tools: Quick Contact Sheet Network Relations Consultant Territory ListingClinical Data Submission ToolsProvider Adjustment FormMedical Policy/Clinical UM GuidelinesClinical EditsProduct and Benefit informationAppeals ProcessProvider Manual
47 Self Service Tools Availity Secure web portal that offers one easy place to take care of administrative, clinical and financial health plan tasks-one site for your transactions with multiple health plan.EligibilityBenefitsClaimsPatient Care SummaryCare RemindersInteractive Care ReviewerImaging and Specialty RXSecure MessagingMember CertificatesPayer Resources TabClick Wrap Registration
48 Question and AnswerIn most of Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.