1. Blue Cross and Blue Shield of Kansas 2014 Hospital Quadrant Meeting

2. www.bcbsks.com www.availity.com
Today's Presenters
Sally Stevens
Provider Representative for Southern Kansas,
Institutional Relations, BCBSKS
   Cindy Garrison, CPC
Provider Representative for Northern Kansas,
Connie Winkley
Education Coordinator, Institutional Relations,
Blue Cross and Blue Shield of Kansas  
Marie Burdiek
Account Representative, Electronic Data Interchange (EDI), Blue Cross and Blue Shield of Kansas

3. Today's Agenda Introduction
Medicare Advantage billing guidelines for other Blue Plans
Present on Admission (POA) Indicator
BlueCard
Inpatient Electronic Precertification
Other Party Liability (OPL)
2015 Policies & Procedures
Quality-Based Reimbursement Program (QBRP)
Electronic Data Interchange (EDI)
Q & A

4. 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.

5. 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:

6. 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
A provider's contracting status with the Centers for Medicare & Medicaid Services (CMS) determines MA payment allowances
MA claims cannot and will not be processed pursuant to BCBSKS Policies and Procedures
Member's Plan is solely responsible for determining pricing

7. 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

8. 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

9. PRESENT ON ADMISSION (poa)
Mandated in 2005 that providers report POA indicators for all diagnoses submitted on Medicare inpatient acute care claims effective October 1, 2007
POA is the condition(s) present at the time the order for inpatient admission occurs.
Differentiates condition(s) present at time of admission from those that develops during the admission.
Providers must report one of five indicators:
Y = yes (present at the time of inpatient admission)
N = no (not present at the time of inpatient admission)
U = unknown (documentation is insufficient to determine if condition was present at the time of admission)
W = clinically undetermined (provider is unable to clinically determine whether condition was present on admission)
Blank (electronic claims) or 1 (paper claims) = exempt from POA reporting

10. PRESENT ON ADMISSION (poa)
Present On Admission FAQs
Q – When is POA data required on BCBSKS claims?
A – POA reporting requirements applies to inpatient claims where MS-DRG assignment is required to determine payment. Includes swing-bed and skilled nursing facilities claims and rehabilitation and psychiatric units.   
Q – Does POA reporting apply to outpatient or ambulatory surgery services?
A – No, this program is only for inpatient acute care admission.
Q – What facilities are exempt from the POA reporting?
A. – When Medicare primary facilities do not need to report POA on the BCBS secondary claim.
Q – When reporting a POA indicator for exempt diagnosis codes, do I use a "blank" or a 1?
A – For electronic claim submission no indicator is required. Leave the position "blank". For paper claims, BCBSKS prefers reporting a "1" verse leaving an exempt code blank.
Q – If the POA indicator is not on the claim, will the claim be returned?
A – Yes, the claim will be returned to the hospital for correct submission of the POA information.
Q – Are Skilled Nursing Facilities and swing beds exempt from billing with the POA indicator?
A – No. POA reporting is required for SNF and swing-bed units.

11. BlueCard Program The BlueCard Program:
Enables a member of one Blue Plan to obtain services while traveling or residing in another Blue Plan's service area.
Allows providers to submit claims for patients from one Blue Plan (domestic and international) to the local Blue Plans.
BCBSKS is your one point of contact for all BlueCard claim-related issues.
Exempt from the BlueCard Program:
Stand-alone dental
Prescription drugs
The Federal Employee Program (FEP)

12. BlueCard Program BlueCard ID Number:
The majority of Blue-branded ID cards display a three character alpha prefix in the first three positions of the subscriber's ID number.
Alpha prefix is necessary for inquiries and proper claims filing.
A Blue member ID number includes the alpha prefix in the first three positions and all following characters (between 6 and 14 numbers/letters) for a total of 17 characters.

13. BlueCard Program BlueCard Suitcase Logos: Blank (empty) Suitcase
PPO in a Suitcase
No Suitcase
Limited Benefits Product ID Cards include one or more of the following:
Product names
Green stripe at the bottom of the card
Limited benefits product statement on the front or back of the ID card
Black cross and/or shield to differentiate it from other ID cards

14. BlueCard Program Coverage and Eligibility Verification:
Eligibility and benefits for out-of-area members can be verified through the Availity Web Portal or by using real time transactions through your clearinghouse.
For additional information on out-of-area members, contact BlueCard at BLUE (2583)
Utilization Review:
Always verify benefits with the member's Blue Plan prior to providing services.
Eligibility and benefits for out-of-area members can be verified through the Availity Web Portal or by using real time transactions through your clearinghouse.
Claims Filing:
Always submit BlueCard claims to BCBSKS
Always include entire member ID #
Do not send duplicate claims. Visit the Availity Web Portal to check claim status.

15. BlueCard Program Medical Records Request: Adjustments:
The request for records will be sent to contracting providers by BCBSKS.
Non-contracting providers could receive record requests from either BCBSKS or the plan where the member is enrolled.
The request will clearly indicated what records are needed and where the records should be sent.
BCBSKS prefers the provider faxes the records, if possible.
Providers are encouraged to respond within 10 days.
Once the records are received, BCBSKS will forward records to the member's home plan for review.
Adjustments:
Contact BCBSKS if an adjustment is required. BCBSKS will work with the member’s Blue Plan for adjustments.

16. BlueCard Program Appeals: Other Party Liability (OPL) Claims:
Provider may appeal on the member's behalf.
Provider should complete Claim Appeal Representative Authorization Form located on the BCBSKS Website.
BCBSKS will forward appeal to the member's Blue Plan and notify the provider.
Other Party Liability (OPL) Claims:
Providers file a secondary BlueCard claim to BCBSKS
When the Blue member is covered by more than one health plan and:
One plan is BCBSKS and one plan is another Blue Plan, then a separate claim should be filed under each ID number.
BCBSKS or another Blue Plan is primary, then submit other carrier's name and address with the claim to BCBSKS. Include the OPL information with the claim.
A non-Blue plan is primary and BCBSKS or another Blue Plan is secondary, then submit the claim to BCBSKS only after receiving primary payment.
NOTE: Timely filing guidelines apply to all BlueCard claims, including those that are secondary to another health plan.

17. Availity

18. Availity

19. Availity

20. Availity

21. Electronic Inpatient Precertification
Updates:
Requirement to submit inpatient precerts electronically has been part of the provider contract for many years.
Submitting precerts electronically is now a measure for the 2015 Quality-Based Reimbursement Program (QBRP)
QBRP measure is outlined in provider's contract
Meet the measure and potentially receive increased reimbursement
If the provider is experiencing technical difficulties with submitting the precert electronically, then that will be taken into consideration when analyzing whether or not the provider has met this QBRP measure.
If you are experiencing problems with accessing the BCBSKS precert system let us know ASAP.

22. Electronic Inpatient Precertification
Training & Education:
Available as a one-on-one visit and webinars
Available for new precert staff
BCBSKS Electronic Precert E-learning tool coming soon. Will notify precert staff by when available.
Required Addresses:
Provider's precert staff will receive information/ s on the precert system only without receiving all other notifications through BCBSKS eNews.
No PHI/Clinical patient information will be shared via

23. Electronic Inpatient Precertification
Electronic Provider Access (EPA):
Electronic Pre-Service Review for out-of - area providers. Providers use local Blue Plan portals to be routed to the Home Blue Plan portal for submitting pre-service review.
January 2014 – EPA tool is available for 33 Blue Plans.
July 2014 – EPA is required to be used by providers for those Blue Plans who make it available .
Plans may request medical records from providers if pre-service review is not submitted electronically by the provider for those Blue Plans who make it available.
EPA is only for initial precert; not for submitting reviews or discharge dates.

24. Electronic Inpatient Precertification
Electronic Provider Access (EPA)
Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the Pre-Service Review link.

25. Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the Pre-Service Review link.

26. Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the Pre-Service Review link.

27. Electronic Inpatient Precertification
Electronic Provider Access (EPA) – 3 possible outcomes
Providers can access EPA from the BCBSKS Web Portal (BlueAccess) through the Pre-Service Review link.

28. Electronic Inpatient Precertification
System Requirements, Access Issues and Potential Errors
Successful use of the electronic precertification system requires access to Availity, BlueAccess and InterQual
Using an Operating System or an Internet Explorer (IE) version that is not compatible; i.e. IE 10 is not compatible with InterQual.
Selecting wrong NPI. The system will not tell you that you have selected the wrong NPI, but instead gives the provider an error message.
The provider may get a blank screen when trying to access InterQual which requires the provider to clean their web browser history.
SAML error – problem with the single sign-on between Availity and BCBSKS. Notify BCBSKS if you receive this error message.
If you are unable to electronically precert an inpatient stay due to system access issues, please inform BCBSKS ASAP!

29. Electronic Inpatient Precertification
Reminders:
Contracting providers shall provide notice for all BCBSKS members admitted for inpatient care. This notification will be required at one of the following:
Prior to admission
The day of admission
The first working day following a weekend or holiday
BCBSKS upgrades their precertification system with the newest InterQual version every July.
BCBSKS has a Precertification web page with tools and resources available on the BCBSKS Website at
See handout material for additional list of important reminders and contact information.

30. Other Payer Liability (OPL)
Functions of the OPL Department:
Determines whether services are eligible for coverage under another insurer.
Assigns primary liability with the correct carrier
Determines if worker's compensation or auto insurance is involved
Their activities help contain costs that affect rates paid by our members.
Does not coordinate with Medicare or Medicaid
Submitting an OPL Claim:
If the member is covered under two different insurance carriers:
File a claim with both carriers and include information regarding the other carrier on each claim.
When an Explanation of Benefits (EOB) is received from the first or primary carrier, it should be sent to the secondary carrier's OPL department. It should NOT be re-filed with another claim form.
If two BCBSKS group policies are involved, then BCBSKS will coordinate these for you with one filing.
If one or both BCBSKS policies are non-group, then a claim must be filed under each ID # separately.

31. Other Payer Liability (OPL)
Timely Filing:
Protects providers from the possibility of receiving a timely-filing denial
If it has been15 months or more from the DOS and the claim is then filed, then the claim will be denied for not filing in a timely and will be a provider write-off
OPL and BlueCard :
Providers should file a secondary Host claim to BCBSKS just as a claim for any Kansas Plan member.
If the patient is covered under another Blue Plan and a BCBSKS Plan, a separate claim will need to be filed under each ID number.
Inquiries regarding overpayments on claims paid by BCBSKS as the Host Plan that have resulted from payment made by another carrier should be directed to our Customer Service Center at (785) Do not direct these inquiries to the OPL department.

32. Other Payer Liability (OPL)
Avoiding Delays:
Provide OPL with the information prior to or at the time of filing your claim.
A form for providers to request a deduction of OPL related overpayments is also available.
Both the OPL Questionnaire and the OPL Deduct Authorization form can be found on the BCBSKS Website at:
Send or fax completed forms to the BCBSKS OPL Department:
Blue Cross and Blue Shield of Kansas
Attn: OPL cc217D5
1133 SW Topeka Blvd
Topeka, KS
Fax to OPL: (785)

33. Other Payer Liability (OPL)
Reconciling your account:
Refer to the EOBs from each carrier
Apply the following rules:
If the patient is not an FEP member or the provider contracts with the primary carrier, then the provider accepts primary payer's write-off.
If the patient is an FEP member or the provider does not contract with the primary payer, then:
the provider determines write-off by subtracting the lesser allowance for any contracting carrier from the total charge(s).
the patient's responsibility is found by subtracting provider the write-off and the primary and secondary payment from the total charge(s).
If the patient responsibility after the primary carrier's payment is greater than the BCBSKS allowance, then the provider must accept the BCBSKS write-off.
An overpayment may result when one or both policies does not coordinate benefits and both parties pay as primary. In this case the overpayment is refunded to the patient by the provider.

34. Other Payer Liability (OPL)
Remittance Advice (RA):
RA helps the provider in identifying a claim involving OPL.
The BCBSKS RA for secondary payments will show:
amount paid by the primary carrier
amount paid on the secondary claim
amount of patient responsibility
total provider write-off after taking into consideration the benefits of both carriers
This eliminates the need to retrieve the primary carrier EOB for balancing patient accounts.

35. Other Payer Liability (OPL)
Remittance Advice (RA):
Listed below are specific coding combinations on the RA that helps the provider in identifying a claim involving OPL.
OPL Code(s) on RA
Coding Details
ARC = 23
Paid as secondary carrier
ARC = 227 (16 for FEP) RMK = N179
Awaiting a response to an OPL questionnaire sent to the patient.
ARC = 22, RMK = N598
The primary carrier must process first and an EOB for the Primary Carrier is required (OR) the EOB from the primary carrier does not match this claim.
ARC = 23, RMK = M43
The primary carrier’s payment exceeds the amount payable under the patient’s contract. No secondary payment is available.
ARC = 19, RMK = MA04
The service is due to a job-related illness or injury (Workman’s Compensation Applies).
ARC = 21, RMK = MA04
The service is due to a motor vehicle related accident (Automobile Insurance Applies).
ARC = 23, RMK = MA04
The patient has accepted a financial settlement form another insurance carrier for this claim.

36. Other Payer Liability (OPL)
OPL Exclusions
BCBSKS contracts contain an exclusion section which outlines conditions for which benefits will not be provided. Among these exclusions are:
Worker’s Compensation
Services provided as the result of work related injury or illness will not be covered by BCBSKS when the patient is covered (or required to be covered) by worker’s compensation law.
No-Fault Auto
Benefits will not be provided for services resulting from accidental bodily injuries due to a motor vehicle accident to the extent that the services are payable under any medical expense payment provision of any automobile insurance policy.
Don't wait to receive a payment from these carriers, go ahead and file the claim to BCBSKS to avoid a timely filing denial.

37. Other Payer Liability (OPL)
Subrogation
Subrogation is defined as "The substitution of one for another as creditor so that the new creditor succeeds to the former's rights or obligations".
Recover of payment due to a 3rd party liability.
Recoveries and inquiries into and/or regarding subrogation are outsourced by Blue Cross and Blue Shield of Kansas to:
The Rawlings Company
One Eden Parkway
PO Box 49
LaGrange, KY   
Providers may inquire as to whether a group has a subrogation rider through the OPL department. 

38. 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:
Blue Choice network
Limited network with in-state contracting providers only
Empty Suitcase
Sold to individuals on and off the exchange and small group (SHOP) markets
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

39. 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

40. 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.

41. 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.

42. 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

43. Quality-Based Reimbursement Program (QBRP)
QBRP 2015 Outline
Mailings
Period 1: July 11, 2014
Period 2: January 31, 2015 (If provider needs another copy)
Effective Dates
Period 1 January 1, 2015
Period 2 July 1, 2015
Letters
Reminders: Period 1: Oct. 29, 2014 Period 2: April 29, 2015
Submission Confirmation: Will be ed within 10 days of BCBSKS receiving attestation
Results: Period 1: Dec. 15, 2014 Period 2: June 15, 2015
Deadlines
Must report by: Period 1: Nov. 15, 2014 Period 2: May 15, 2015

44. Quality-Based Reimbursement Program (QBRP)
QBRP Forms and Notifications:
Form can be submitted by paper or electronically. Electronic form was available on BlueAccess beginning August 18th.
Paper forms can be faxed to Brent or ed to
Confirmation of receipt of the form will be sent within 10 days to the provider.
Result letters will be mailed to providers within 30 days.
Details of the 2015 QBRP were in included in the provider contract mailed in July.

45. Quality-Based Reimbursement Program (QBRP)
Incentive Increases:
Incentives earned will be applied to inpatient MS-DRG maximum allowable payments (MAPs) and outpatient MAPs except for reference laboratory and pharmacy and services that have a charge less than the MAP.
QBRP Prerequisites include:
Electronic remittance advices
Use of BCBSKS electronic portal for inpatient hospital precertification and continued stay reviews
Obtain eligibility, benefit and claim status information primarily through electronic transactions