TODAY'S PRESENTERS  Janne Denton Contract Consultant & Specialty Provider Rep, Institutional Relations, Blue Cross and Blue Shield of Kansas  Connie Winkley Education Coordinator, Institutional Relations Blue Cross and Blue Shield of Kansas  Brent Matile Provider Program Specialist Blue Cross and Blue Shield of Kansas  Marie Burdiek Electronic Data Interchange (EDI) Account Representative Blue Cross and Blue Shield of Kansas

AGENDA  Introduction  Institutional Relations Department  BCBSKS Website & Availity  Grace Period (Affordable Care Act)  Medicare Advantage  2015 Policies & Procedures & MAPs  Quality-Based Reimbursement Program (QBRP)  Electronic Data Interchange (EDI)

Who are we and what do we do?

Institutional Relations (IR) Org Chart Sally Stevens, Provider Rep Hospitals in Southern KS Cindy Garrison, Provider Rep Hospitals in Northern KS Teresa Van Becelaere Manager, IR Angie Strecker, Director Institutional Relations Dona Hewes Administrative Coordinator, IR Fred Palenske, Senior VP Provider and Government Affairs Connie Winkley Education Coordinator Janne Denton Contract Consultant & Provider Rep Katie Dennison Claims Research Analyst Brent Matile Provider Program Specialist Melanie Moriarty Administrative Assistant (Topeka) Kristi Donelan Administrative Assistant (Wichita)

Institutional Relations Functions  IR Functions Include:  Provider Contracts  Mailed annually in July  Includes our Quality-Based Reimbursement Program (QBRP)  Contracts with and services the following facilities:  Hospitals – CAH, PPS, Specialty, Limited Services, VA  ASCs  Home Health  Hospice  Dialysis Facilities  Skilled Nursing Facilities  Education and Training  Workshops  Webinars  One-on-one provider visits  Training as requested  Newsletters and Manuals  eNews  Relevant Topics – i.e. ICD-10

Institutional Provider Relations  IR Functions include:  Provider Claims Resolutions  Katie Dennison – Claims Research Analyst  Provider Representative  Any IR staff member  Provider Liaison Committees  Solicit input from surgical groups – i.e. Optometrist, Audiologist, etc.  Assist in the review and development of BCBSKS medical policies

BCBSKS Website Public information includes:  Medical Policies  Forms  ICD-10 Web page  Precertification/Prior Authorization Information for Blue Plans  Newsletters and Latest News (eNews)  SOK & FEP web pages

Availity and BlueAccess  Availity (  Single sign-on to Availity and BlueAccess  Eligibility & Benefits  Claims Status  Availity Training  Workshops  Webinars  Provider Visit  Availity to BlueAccess  Link through Payer Resources  Secure tools on BlueAccess include:  Remittance Advice  Member ID Look-up  Manuals  Some forms that can be sent electronically  QBRP Form

Affordable Care Act (ACA) Grace Period  Exchange Individual Grace Period  ACA mandates a three-month grace period for those insured through the Exchange who receive a subsidy.  Individual has paid at least one month's premium  The payer is only obligated to pay claims during the first month  During the grace period, the payer may pend claims during the second and third months  Payer must notify HHS of non-payment of premiums  Payer must notify provider of the possibility of denied claims

Affordable Care Act (ACA) Grace Period Marilyn Monroe 01/01/2000 ABC Female 123 Anystreet Apt. 1 Anytown, KS /14/ /30/ /01/2014 – 12/31/

Affordable Care Act (ACA) Grace Period Rhett Butler 01/01/2000 ABC Male 123 Anystreet Anytown, KS /14/ /30/ /01/2014 – 12/31/2014 Billy Butler ABC

Medicare Advantage Medicare Advantage (MA) facilitates the coordination of Blue Plan Medicare Advantage claims and services for members and providers. MA products must cover the same services as original Medicare Part A/B and may include additional benefits. MA has expanded to allow Plans to offer several types of MA products. CMS Employer Group Waiver Guidance Allows MA PPO and HMO groups to enroll members in areas where provider networks do not exist.

Medicare Advantage MA Private Fee-for-Service (MA PFFS) Member may receive services from any Medicare provider that accepts the Home Plan's terms and conditions. Identifying a MA member:

Medicare Advantage MA Claims Submission Submit all Medicare Advantage claims to BCBSKS Do not bill Medicare directly for any services rendered to a Medicare Advantage member Payment will be made directly by a Blue Plan MA claims cannot and will not be processed pursuant to BCBSKS Policies and Procedures Member's Plan is solely responsible for determining pricing

Medicare Advantage MA Claims Submission Home Plans need the following to adjudicate MA claims accurately and timely: National Provider Identifier (NPI) Source of Referral for Admission (one alpha-numeric character indicating transfer or admission) Core Based Statistical Area Treatment Authorization Code Admitting Diagnosis Code Height and Weight for End-Stage Renal Disease (ESRD) patients Ambulance Pick-Up Zip Code HIPPS Code for Home Health, Skilled Nursing and Inpatient Rehabilitation Taxonomy Code (if the provider represents an institutional with more than one subpart to bill) Certified Registered Nurse Anesthetists (CRNA) Special Code Provider Service Location ZIP Code, if different than the billing ZIP Code Present On Admission (POA) Indicator

Medicare Advantage MA Appeals Reason for appeal may include:  A delay in providing, arranging for or approving healthcare services  The amount a member must pay for a service Appeals can be submitted by  Member  Provider  Assignee or the member's legal representative Appeals submission:  Submit to BCBSKS  BCBSKS forwards to member's plan within 3 days of receipt  Member's MA Plan will respond to provider within 30 days Member's plan determines medical policy Provider agrees to abide by final determination Obtain appeals policies and procedures from the MA Plans

2015 Policies & Procedures Updates and Changes: Language was added to the provider contracts that encompasses all subsidiaries of BCBSKS  A new BCBSKS Subsidiary (a Health Maintenance Organization (HMO)) known as Blue Solutions will be sold to consumers soon with an effective date of January 1, 2015: o Blue Choice network o Limited network with in-state contracting providers only o Empty Suitcase o Sold to individuals on and off the exchange and small group (SHOP) markets o Blue Solutions is not a traditional HMO:  Members will not choose a Primary Care Provider (PCP)  No referral is needed for visiting a specialty provider  Members have open access through the BCBSKS Blue Choice network  Providers reimbursed using Blue Choice payment rates

2015 Policies & Procedures Blue Solutions The following alpha prefixes will be used for Blue Solutions members: XSC - Individual Exchange Solutions XSG - SHOP Exchange Solutions XSQ - Individual Solutions Off-Exchange XSR - Small Group Solutions Off-Exchange

2015 Policies & Procedures Updates and Changes: Language was added to specify a timeframe for organizing a First Level Appeal Panel BCBSKS has a credentialing program which:  consists of an initial full review of the providers credentialing application with re-credential at a minimum of every 36 months.  monitors of all network providers for continual compliance with established criteria will occur as needed, but not less than monthly. If a provider does not meet credentialing requirements, they will not be allowed to participate as a network contracting provider. Providers may appeal this decision by following the appeals process outlined in the Policies and Procedures. Credentialing Program requires BCBSKS to have an appeals panel and BCBSKS will have 60 days from receipt of the appeal to organize the appeals panel.

2015 Policies & Procedures Updates and Changes: A section was added to the P&P to further define the confidentiality provision. BCBSKS requires that all proprietary information be kept confidential. The contracting provider may not disclose any terms of the Agreement to the third party except upon written consent of BCBSKS and as required by state or federal law. Added language to strongly encourage contracting providers to use the Limited Patient Waiver (LPW).  A waiver should be used for a variety of reasons included the service is not medically necessary, the benefit is denied per the member contract or the service is considered Experimental or Investigational.  Some providers have their own waivers and they may not meet BCBSKS Requirements. If providers want to use your own waiver form to verify that it includes everything that is on the BCBSKS waiver, then please have your BCBSKS rep review your waiver form.

2015 Policies & Procedures Updates and Changes: A section was added outlining the administrative disputes process to comply with health plan accreditation guidelines.  This is not new; just clarification  Provider may dispute issues of concern through their BCBSKS Rep  Rep will work with the provider to address the dispute  Dispute may be escalated to BCBSKS management, if unresolved  BCBSKS will provide written response within 60 days of management receiving the request

2015 MAPs Code Changes Based on additional information submitted by providers, the maximum allowable payments (MAPs) for the following procedures will be increased in 2015 and additional codes will be added in ASC MAP'd Codes Increased for ASC Codes Added in

2015 MAPs Payment attachment changes: Page 6, Contract Amendments A provision was added to amend the Contracting Provider Agreement whereby BCBSKS could make adjustments to the maximum allowable payment (MAP) for services. "The Contracting Provider Agreement is hereby amended to delete Section IV. B which references certain circumstances under which BCBSKS could make adjustments to the maximum allowable payment (MAP) for services. If the Contracting Provider has signed the Blue Choice Agreement, then Section IV.3 is also amended."

Quality Based Reimbursement Program (QBRP) Overview Reporting periods Period 1 is due by November 15, 2014 Period 2 is due by May 15, 2015 Effective dates Period 1 incentives will be effective January 1, 2015 Period 2 incentives will be effective July 1, 2015 Data submissions Period 1 – attestations only Period 2 – data from all of CY 2014 Incentive increases Incentives earned will be applied to outpatient maximum allowable payments (MAPs) and do not apply to services with a charge below the MAP.

QBRP Prerequisites I attest that this facility will file all claims electronically I attest that this facility will accept electronic remittance advices Obtain eligibility, benefit and claim status information primarily through electronic transactions

Quality Measure 1 (QM1): Prophylactic Intravenous (IV) Antibiotic Timing (CMS ASC-5) Period 1:  Attest that this facility has a process in place to ensure that antibiotic infusion is initiated within one hour prior to the time of the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are administered. Period 2:  Numerator: Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infections (SSI) who received the prophylactic antibiotic on time  Denominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection Incentive: 1.50%

Quality Measure 2 (QM2): Falls Within the ASC (CMS ASC-2) For Period 1  Attest that a process is in place to capture any ASC admissions experiencing a fall within the confines of the ASC. For Period 2  Report the number of ASC admissions experiencing a fall within the confines of the ASC.  Numerator: falls within the confines of the ASC in CY 2014  Denominator: all ASC admissions Incentive: 1.00%

Quality Measure 3 (QM3): ASC Transfers to Hospital Upon Discharge (CMS ASC-4) For Period 1  Attest that a process is in place to capture any ASC admission (patients) who are transferred or admitted to a hospital upon discharge from the ASC. For Period 2  Report ASC admissions who are transferred or admitted to a hospital upon discharge from the ASC.  Numerator: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.  Denominator: all ASC admissions Incentive: 1.50%

Quality Measure 4 (QM4): Surgical/Procedure Time Out  I attest that this ASC has a time-out protocol which requires a hard stop by all after prep and drape and prior to the start of the procedure. The protocol shall include the following: a) identification of the patient by name b) the procedure is stated c) the marked incision site is visible d) allergies are stated and share with the team and selected prophylaxis antibiotics ordered and given e) The team is asked about any concerns before starting. Concerns are shared with the team and discussed to mitigate risk. Incentive: 0.50%

Form submission  Paper forms can be faxed to Brent Matile at or ed to  The QBRP form is available electronically  Any updates to contact information for Quality Managers should be ed or indicated on the paper form

Questions?