1. BlueShield of Northeastern New York Chiropractic Program

2. Chiropractic Overview Chiropractic Program Provider Relations HEALTHeNET/ ASK/ Provider Website Quality Management Wellness Benefit Health Care Services Future Projects Questions

3. Changing Environment The consumer’s role in health care decision making is expanding Consumers will have more options for how, where, and from whom they purchase health insurance Costs continue to rise and the quality of care needs to improve Government regulations are dramatically changing

4. Beginning January 1, 2013: Chiropractic Program Chiropractic Program MembersEmployersCommunity Chiropractic Committee Health Care Services Pilot Programs Quality Management Provider Services Providers

5. Chiropractic Program Goals Leverage claims data and quality measures to substantiate chiropractic services Decrease spinal surgeries Reduce pharmaceutical dependence –Pain medications and spinal injections –Inappropriate and unnecessary imaging for spinal issues Optimize chiropractic provider network performance –Reduce administrative burden; less paperwork –More time with patients Reduce over- and under-utilization Increase outcomes and reduce risk Align patients and providers Support performance management programs

6. BlueShield of Northeastern New York Chiropractic Advisory Committee

7. Ensure continuing access to high quality, medically appropriate, evidence-based, cost-effective chiropractic care. Maintain a consistent and clinically appropriate approach in the administration of chiropractic care, including development of clinical practice guidelines. Develop clinically integrated programs and quality incentive programs. Aid in the development of coverage criteria, review of coverage decisions, and technology assessments. Review administrative rules pertaining to health care issues that may be related to the delivery of high quality chiropractic care.

8. Chiropractic Advisory Committee Clinical Practice Guidelines Chiropractic Treatment Request Form Policies and Procedures Medical procedures Outcome-based pilot programs Health Care Services programs

9. Chiropractic Committee Commitment Members are appointed by BlueShield for a two- year term beginning with attendance at their first committee meeting and may be renewed for two additional two-year terms. However, to ensure institutional memory of the committee, initial appointments may be extended to three- or four-year initial appointments. After the initial two years of the committees’ existence, one-third of the members will rotate off the committee after two years, one-third after three years and one-third after four years. If members do not volunteer to rotate off the committee, selection will occur via a random name selection process.

10. BlueShield of Northeastern New York Provider Relations

11. The Provider Relations Specialist is your primary link with BlueShield. –Delegated by zip code or territory –Share information and analyze practice patterns in an effort to help you provide quality, cost-effective care Our commitment to partnering with our participating providers is vital to providing quality coverage for our members.

12. Medical Management Model Less cumbersome for the chiropractors. A limited number of BlueShield ASO contracts will still be managed through the preauthorization process. As a result, these members will have unlimited chiropractic coverage. Members and providers will no longer have to complete the paperwork; therefore, access to care is easier with our model. Furthermore, chiropractors will now have a direct line of communication with the health plan and the ability to share recommendations on quality programs and other initiatives.

13. Network Updates Management of Services for chiropractors, massage therapists, and acupuncturists. Open network enrollment: –January 1, 2013 Previously, participating chiropractic providers: –Were dual contracted with Palladian network and the BlueShield network. –Will not need to do anything come January 1, 2013 because your participating provider agreement with BlueShield will automatically become effective.

14. Claim Submission Dates of service December 31, 2012 and prior: –continue to submit to Palladian Health. Dates of services January 1, 2013 and later: –submit to BlueShield for processing and reimbursement –Payor ID: 00800

15. Reimbursement/Fee Schedule for BlueShield Increase in BlueShield fee schedule for initial and established office visits by 5 percent starting January 1, 2013 –All lines of business Re-evaluation fee has been included –Allowed once every 3 months Fee schedule is available on the provider website

16. Provider Credentialing Process (CAQH) Providers can enroll into our health plan by filling out the Universal Credentialing Application with the Council for Affordable Quality Healthcare (CAQH) –Enter your CAQH Provider ID to enter or update your information –Authorize BlueShield to access your information electronically

17. Direct Communication Provider Representatives Provider Website Provider Quarterly Newsletters Yearly Provider Expo Provider Customer Services Chiropractic Advisory Committee

18. BlueShield of Northeastern New York Quality Management

19. Health Insurance Overview InterQual Criteria Chiropractic Authorization Chiropractic Treatment Request Form/Flow Chart Internal Processes Quality Department Fraud/Abuse

20. Health Care Plans and Systems Managed Care Plans –Preferred Provider Organization (PPO) Participants’ care must be provided by selected health care providers, but participants can go outside the network; co- insurance, high deductibles. –Exclusive Provider Organization (EPO) Participants’ care must be provided by selected health care providers, but participants cannot go outside the network; they are completely responsible for payment. –Health Maintenance Organization (HMO) Health care system assumes both the financial risk associated with providing services and responsibility for health care delivery in a particular geographic area; usually a fixed, pre-paid fee. –Point-of-Service (POS) HMO/PPO ‘hybrid’: resembles HMO for in-network services, but services outside of the network are usually reimbursed in a manner similar to fee schedule. Self-Insured Plans –Administrative Services Only (ASO) Employer hires a third party to deliver administrative services such as claims processing and billing; employer bears the risk for claims.

21. Members Requiring Authorizations ASO/Experience Rated Groups (Self-Funded) –Fastest growing types of employee benefit arrangements –Employers are responsible for directly funding all employee claims –Employers pay a fixed fee for administrative services like claim payment and management reporting –An insurance company provides those administrative services, but doesn’t collect any premiums where no insurance risk has been underwritten

22. Chiropractic Visit Restrictions Three Major Limitations: –Medical Necessity Prior Authorization Requirement Can vary from first visit to the twentieth visit –Maximum dollar limit, ex: $200 –Maximum visit limit, ex: 20

23. Clinical Practice Guidelines InterQual Chiropractic Criteria –Created by actively practicing chiropractors across the country. –Promotes evidence-based standards of care. –Accepted by: Chiropractic Advisory Committee Quality Management Committee –Available on the Provider Website

24. Medical Review: Chiropractic Treatment Request (CTR) Provider Office –Checks patient contractual agreement If no limits: treat patient If limits: determine allowable visits Complete the CTR form before contractual visits have been exhausted For example: –If five visits are allowed without medical necessity, complete CTR form after the fourth visit Fax completed forms to BlueShield at 1-716-887-7913 Provider and member will be notified of decision within three days via: –mail –phone call If additional visits are required, submit additional CTR forms

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27. Chiropractic Treatment Request Step 1: – Checked by staff: Eligible member If required Complete Step 2: –Checked by RN: CTR reviewed against InterQual Criteria Additional visits given If unable to make a determination Step 3: –Checked by chiropractor: Combination of InterQual Criteria and clinical judgment

29. Provider Expectations Self Governance –Maintain quality medical records –Comply with HIPAA standards Practice Guidelines –Apply appropriate evidence-based care to members –Ensure BlueShield-accepted clinical guidelines are used –Comply with regulatory agencies

30. BlueShield of Northeastern New York Wellness Benefit

31. The Wellness Card Available with the Aqua plan, Wellness Benefit (formerly Lifestyle Rider), and Healthy Balance, effective January 1, 2013. All subscribers will receive a Visa card to be used with a nationwide network of health and wellness retailers based on merchant type and/or merchant category. –Fitness centers –Massage therapy –Chiropractic visits –Health food stores –And many more! All transactions are handled through Visa and processed through our vendor, Discovery Benefits.

32. The Wellness Card Lifestyle Rider: Effective January 1, 2013 the Lifestyle Benefit will be referred to as the Wellness Benefit. A wellness card will be provided to subscribers of the Aqua plan, Wellness benefit, and Healthy Balance.

33. Senior Fitness Benefit The BlueShield network will be partnering with SilverSneakers, effective January 1, 2013. If you are not currently part of the SilverSneakers network but would like to be, you can submit a request to begin the application process online at silversneakers.com. silversneakers.com If you are already a SilverSneakers provider, no further action is required.

34. BlueShield of Northeastern New York HEALTHeNET Web Application PCI HELP DESK 1-877-895-4724 HOURS OF OPERATION: 7 a.m. - 7 p.m. Monday-Friday

35. EPRO Provider File Updates EPRO Future??? HIPAA Claims Status Transaction HIPAA Referrals Transaction Security: One User ID and Password HIPAA Membership & Eligibility Transaction HEALTHeNET 30,000 + users EPRO Claims Adjustment Requests Administrative Transactions: One Stop Shopping…

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49. Provider Inquiry Transaction

50. Provider Inquiry Summary Transaction

51. Available Inquiry Summaries

52. Provider Inquiry Detail

53. Provider Website bsneny.com

54. Provider Website

55. Network Information

56. Help Me Find

57. News and Events

58. Resources

59. Policies

60. Payment and Operations

61. BlueShield of Northeastern New York Health Care Services

62. Member/Provider Experience Personalized programs Targeted Interventions Diverse Communication

63. Managing the Spectrum of Care 63

64. Advanced Care Coordination Health coaching Case management Disease management Behavioral health Health advocate Tailored clinical mailings Online consultation Outreach Health promotion support and consultation On-site clinical support [CM, DM] On-site workshops Interactive programs Flu shot clinics Biometric assessments On-site Community wellness Program Childhood wellness Initiatives Home care collaboration VNA Community sponsorship opportunities Community Member

65. BlueShield of Northeastern New York Future Projects

66. Educational workshops Chiropractic continuing education Pay for performance pilots Interdisciplinary and chiropractic care connections Patient-centered medical home College collaborations

67. OverviewWhat are the benefits? MemberUnrestricted chiropractic care* Control over their health decisions Improved outcomes Improved overall satisfaction Improved health and well-being Reduction in member health care costs ChiropracticIncrease reimbursement Eliminate paperwork Reduces administrative burden placed on provider, staff, and patient Allows additional time to treat patients Improving satisfaction and outcomes for patient Internal direct contact with BlueShield CommunityMusculoskeletal-specific wellness seminars Collaborate with providers/members to drive performance/quality Improving customer satisfaction: providers, members, employers, and community *Please refer to members contractual agreements for chiropractic coverage

68. We look forward to a long, exciting future Questions? Please contact: BlueShield of Northeastern New York Provider Relations Department 1-518-220-5601