Working with Anthem Subject Specific Webinar Series

Transcription

1 Working with Anthem Subject Specific Webinar Series BlueCard Program Introduction Access to Audio Portion of Conference: Dial-In Number: Conference Code: # Please Mute Your Phone This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

2 Agenda Housekeeping and Announcements BlueCard Program Introduction Medicare Crossover o Submission and duplicate claims handling o Submission and rejection Q&A Medicare Non-Covered (statutorily excluded) Services Ancillary Provider Billing Electronic Provider Access Inpatient Precertification Learn More Questions & Answers 2

3 Navigation and Handouts Click here for handouts 1. Select items by checking the boxes 2. Select a destination on your computer 3. Press OK to download Control your view Full Screen 3

4 BlueCard Is A program launched in 1994 by the Blue Cross and Blue Shield Association that enables Blue members who are traveling or living in another Plan's service area to receive the same healthcare service benefits of their home Plan. A program that 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. BlueCard Is Not A company, a single benefit plan, a computer system. 4

5 The Blues Blue Cross and Blue Shield companies are independent and locally operated. 36 Blue Cross and Blue Shield independent licensees. Collectively providing healthcare coverage for more than 100 million people or one-in-three Americans. Nationally 96% of hospitals and 92% of professional providers contract directly with Blue Cross and Blue Shield companies. Among the 20 largest employers in the U.S. Blue Cross and Blue Shield Brands are registered in more than 170 countries. The Association The Blue Cross and Blue Shield Association (BCBSA) is a national federation of the 36 independent, community-based and locally operated Blue Cross and Blue Shield companies. Provides member plans with brand, operational and performance guidance, a standardize transactional communication system, performance and satisfaction measures. 5

6 The Blues Anthem Blue Plans -14 Anthem Blue Cross and Blue Shield in Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia and Wisconsin Anthem Blue Cross California Blue Cross Blue Shield of Georgia Empire BlueCross BlueShield 6

7 How it works Home and Host The Home Plan Insures or administers the member s benefits Determines rules precertification, medical necessity, etc. Receives and adjudicates priced claims from host plans Transmits claim disposition to host plan Generates member explanation of benefits (EOBs) Financially settles with host plans VZF The alpha prefix is key 7

8 How it works Home and Host The Host Plan Contracts with service providers and sets reimbursement Receives, prices and transmits claims from local providers Receives claim disposition from home plans Generates remittance advice and pays providers Financially settles with home plans VZF The alpha prefix is key 8

9 How it works Interplan Transactions 1. Member of another Blue Plan receives services from you, the provider 2. Provider submits claim to the local Blue Plan 3. Local Blue Plan recognizes BlueCard member and transmits standard claim format to the the member s Blue Plan 4. Member s Blue Plan adjudicates claim according to member's benefit plan 7. Your local Blue Plan pays you, the provider 6. Member s Blue Plan transmits claim payment disposition to your local Blue Plan 5. Member s Blue Plan issues an EOB to the member VZF The alpha prefix is key 9

10 Program Exclusions Federal Employee Program (FEP) Administered separately Medicare Risk Stand-alone dental and prescription drugs Vision and hearing Contiguous counties and contracts ID cards without alpha prefixes When in doubt call WI BlueCard Provider Service at

11 How it works Contacts The Home Plan Eligibility, Benefits and Precertification Telephonic BLUE (2583) 270/271 EDI Transactions Availity Secure Multi-Payer Portal VZF The alpha prefix is key Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on 11 11

12 How it works Contacts The Host Local Plan Single point of contact for post service communication Claim submission, status, adjustment requests, questions Telephonic /276 Claim Status Availity Secure Multi-Payer Portal o Claim Status Inquiry o Secure Messaging VZF The alpha prefix is key Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on 12 12

13 Medicare Crossover Purpose Ensure timely and accurate payment for secondary payer Medicare claims. Blue Crossover Guidelines In response to provider requests 13 13

14 Medicare Crossover Submission and duplicate claims handling When a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting the claim to the local Blue Plan to avoid claim returns. o Providers should continue to submit services that are covered by Medicare directly to Medicare. o Even if Medicare may exhaust or has exhausted its benefits, continue to submit claims to Medicare to allow for the crossover process to occur and for the member s benefit policy to be applied. o Local Blue Plans will reject provider submitted claims received within 30 calendar days of the Medicare remittance date or any claims received without a Medicare remittance date on the claim

15 Medicare Crossover Submission and duplicate claims handling Medicare primary provider-submitted claims will be rejected back to the submitter with the following conditions: o Medicare advice remark codes MA18 or N89 that indicate Medicare crossover has occurred. MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them. N89 Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice. o Received by provider s local Blue Plan within 30 calendar days of Medicare remittance date. o Received by provider s local Blue Plan with no Medicare remittance data

16 Medicare Crossover Q&A How do I submit Medicare primary / Blue Plan secondary claims? For members with Medicare primary coverage and Blue Plan secondary coverage, submit claims to your Medicare intermediary and/or Medicare carrier. When submitting the claim, it is essential that you enter the correct Blue Plan name as the secondary carrier. This may be different from the local Blue Plan. Check the member s ID card for additional verification. Be certain to include the alpha prefix as part of the Blue Plan member s identification number. The member s ID will include the alpha prefix in the first three positions. The alpha prefix is critical for confirming membership and coverage, and key to facilitating prompt payments

17 Medicare Crossover Q&A How do I submit Medicare primary / Blue Plan secondary claims? Continued When you receive the remittance advice from the Medicare intermediary, look to see if the claim has been automatically forwarded (crossed over) to the Blue Plan: o If the remittance indicates that the claim was crossed over, Medicare has forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in process. There is no need to resubmit that claim to the local Blue Plan. o If the remittance indicates that the claim was not crossed over, submit the claim to your local (Wisconsin) Blue Plan with the Medicare remittance advice (if sending a paper claim, or indicate the primary payer information in the appropriate loops/segments on the 837 electronic claim). o In some cases, the member identification card may contain a COBA ID number. If so, be certain to include that number on your claim

18 Medicare Crossover Q&A When should I expect to receive payment? The claims you submit to the Medicare intermediary will be crossed over to the Blue Plan only after they have been processed by the Medicare intermediary. This process will take a minimum of 14 days. This means that the Medicare intermediary will be releasing the claim to the Blue Plan for processing about the same time you receive the Medicare remittance advice. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional business days for you to receive payment or instructions from the Blue Plan

19 Medicare Crossover Q&A What should I do in the meantime? If you submitted the claim to the Medicare intermediary/carrier, and haven t received a response to your initial claim submission, do not automatically submit another claim. Rather, you should: o Review the automated resubmission cycle on your claim system. o Wait 30 calendar days from receipt of the Medicare Remittance advice. o Check claims status with Medicare before resubmitting Sending another Medicare claim, or having your billing agency resubmit claims automatically, actually slows down the claim payment process and could create confusion for the member

20 Medicare Crossover Electronic Secondary Claim Submissions - Help Call the Anthem s E-Solutions HelpDesk at or, Go to to request assistance with submitting electronic claims to Anthem BlueCross and BlueShield of Wisconsin. If you have questions about where to file your paper claim: Please see our Ready Reference Guide available on our public provider website under Contact Us. Call the provider call center at the phone number on the back of the member s ID card

21 Medicare Non-Covered Services Providers who render statutorily excluded services should indicate these services by using the GY modifier at the service line level of the claim. Providers will be required to submit only statutorily excluded service lines on a claim (cannot combine with other services like Medicare exhaust services or other Medicare covered services). The provider s local Blue Plan will not require a Medicare EOMB. If providers submit combined line claims (some lines with GY, some without) to their local Blue Plan, the provider s local Blue Plan will deny the claims, instructing provider to split the claim and resubmit

22 Medicare Non-Covered Services We will reject Medicare primary provider-submitted claims with the following conditions (continued): o Received with GY modifier on some lines but not all A GY modifier is used by providers when billing to indicate that an item or service is statutorily excluded and is not covered by Medicare. o Examples of statutorily excluded services include hearing aids and home infusion therapy

23 Medicare Non-Covered Services These processes align with industry standards and will result in: Less administrative work More accurate payments Fewer rejected claims Lower out-of-pocket costs for members due to less balance billing of members 23 23

24 Ancillary Provider Billing Ancillary Provider Claim Submission Reminder Independent Clinical Lab o File to the Plan whose service area where the specimen was drawn. o Determined by the zip code associated with NPI Durable/Home Medical Equipment o File to the Plan in whose service area the equipment and/or supplies were delivered, shipped to, or o the location of the retail store where the equipment and/or supplies were purchased or rented

25 Ancillary Provider Billing Ancillary Provider Claim Submission Reminder Specialty Pharmacy o File to Plan in service area ordering provider located (ordering physician address) o Determined by the zip code associated with NPI Applies to all Commercial and Medicare Advantage Blue Plans Does not apply to Federal Employee Program (FEP) members More Information go to Answers@Anthem, Ancillary Claim Filing Requirements FAQs September, 2012 at this link: 24.pdf?refer=ahpprovider&state=wi Important Reminder: Contracted practitioners are required to refer/order services from other participating providers

26 Electronic Provider Access Inpatient Precertification BlueCross and BlueShield Association mandate Tool accessed through Availity Auths & Referrals to Anthem s Interactive Care Reviewer (ICR) Providers responsible for obtaining pre-service review (precertification / preauthorization) for inpatient services effective July 1, Notification of emergency/urgent admissions within 72-hours. Providers notify the member s Home Plan within 48-hours when a change to the original pre-service review occurs. Members held harmless for penalty reductions if inpatient admission is not precertified. Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on 26 26

27 Electronic Provider Access Inpatient Precertification To access ICR from the Availity Web Portal choose Authorizations under the Auths and Referrals link on the left navigational bar. Availity Web Portal at Now, as part of the Electronic Provider Access (EPA) mandate, providers will need to enter the member alpha prefix and the service dates. Routing will be based on the prefix entered. Users will be prompted to add Tax ID and NPI for an out of area provider

28 Electronic Provider Access Inpatient Precertification Provider Requirements Obtain pre-service review for out-ofarea members, same as local members. Notify member s Plan of change in pre-service approval within 48-hours. Notify member s Plan for emergency /urgent pre-service review within 72 hours. Inpatient* facility services only. Hold out-of-area members harmless. Sanctions are in the contract with local Blue Plan EPA tool available in 2014 Member Benefits Out-of-area and local members are treated the same for precertification requests. Consistent and more seamless care management processes for members. Members not held liable for preservice sanctions if a facility does not obtain precertification. Members remain responsible for medical necessity determinations. *Inpatient facilities include hospitals, skilled nursing and inpatient rehabilitation facilities

29 Learn More On the web at select Providers under Other Anthem Websites, Choose Wisconsin from the drop down box and press Enter.Communications o Provider Home Page ICR Training Register for free training webinars at the link on the Provider Home page or choose this link: me=83vbvn5cvr00ngx4 o General Information BlueCard Claims Filing BlueCard Program Provider Manual 29 29

30 Learn More continued On the web at select Providers under Other Anthem Websites, Choose Wisconsin from the drop down box and press Enter. o Answers@Anthem Timely and Accurate Payment for Secondary Payer Medicare Claims o Ready Reference Guide on the Contact Us page o Blue Cross and Blue Shield Association Website at

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32 Working with Anthem Subject Specific Webinar Series Please complete the Webinar Evaluation Survey o Individuals completing the evaluation survey within 2 business days will be eligible for a Blue Prize package. o Winner will be notified by within 3 business days. Thank you for attending Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association