10/30/2017. Third Party Payer Day: Medicare Plus Blue Claims & System Issue Resolution. Provider contacts Provider Inquiry Service Center

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1 Third Party Payer Day: Medicare Plus Blue Claims & System Issue Resolution November 10, 2017 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Teri Findley, Manager MA Servicing Administration PROVIDER INQUIRY PROCESS Provider contacts Provider Inquiry Service Center Provider contacts Service Center to address claim concerns related to: Partial payment Claim denial Request for Medical Records Provider Inquiry Representative will determine based on concern above: If first level appeal process should be invoked If medical records are required NOTE: Initial claim denials for medical documentation are not handled as a provider appeal. 1

2 Provider Appeal Types There are two types of provider appeals Level I Level II Provider appeals typically consist of: Timely Filing (Not appealable to Level II) Payment Disputes o Billing Errors (Not appealable to Level II) o Processing Errors Preauthorization Medical Necessity Provider Appeal Timelines Level I Appeal Accepted - phone or written Timely Filing (handled as payment reconsideration) Payment disputes (unrelated to denials or retrospective audits) o Must be submitted within 120 days from the initial payment date o Timeline for response provided within 60 days from the time we receive the dispute Claim Denials, Authorizations and/or Medical Necessity o Must be submitted within 60 days from the initial denial o Timeline for response provided within 60 days from receipt Level II Appeal Accepted - written only All types (except Timely Filing and Billing Errors) o Must be received within 60 days of receiving written notice of Level I decision o Timeline for response provided within 60 days from receipt o Decision is final and binding Processing Level I Appeals Timely Filing Disputing timeliness based on previous submissions will be handled as reconsideration Provider must submit proper documentation showing claim was sent and accepted by BCBSM via electronically or mail. A screen shot of the provider or vendor billing system IS NOT sufficient documentation to override timely filing. If the documentation is insufficient, the provider will receive a Timely Filing Denial Letter. NOTE: All providers have 1 year from date of service to file clean claims and corrections of claim per the PPO Manual and their provider agreement which align with MEDICARE guidelines. Delay to timely filing by BCBSM will be automatically waived. 2

3 Processing Level I Appeals cont d Payment Disputes Providers should call the Service Center to verify why the claim paid incorrectly. o Processing errors may be the result of a system defect and cannot be adjusted at the time of the request from the provider. o Billing errors cannot be adjusted by a Provider Service Rep. The only way to change an MA claim is to submit a corrected claim. If additional documentation is needed to resolve the dispute, the Provider Service Rep may call or send a written request for information. Based on the outcome of the appeal: o Favorable Provider voucher will serve as notification o Unfavorable Provider Service Rep will send a written response with rationale of decision Processing Level I Appeals cont d Preauthorization Appeals If there is no authorization confirmed in our system, a Level I preauthorization denial letter with appeal rights is sent to the provider. If an authorization is confirmed in our system, the claim will be sent with the authorization information for reprocessing to our claims team. Medical Necessity Appeals If the claim requires submission of medical records, provider should do so within the filing guidelines. All supportive/medical documents must be submitted hard copy with a corrected claim to the Medicare Advantage mailing address. Supportive/medical documents cannot be submitted electronically for Medicare Advantage. Processing Level I Appeals cont d Medical Necessity Appeals Supportive/medical documents are reviewed by the Provider Inquiry Rep for completeness and sent to RN for clinical review o If Clinical Review requests additional information, the provider will receive a call or an information request letter - If Provider does not respond timely, a Level I Denial/Appeal Letter will be mailed citing failure to submit required documentation. o If Clinical Review denies for not meeting criteria, the provider will receive a Level I Denial/Appeal letter citing reason for denial 3

4 Level II Provider Appeals Payment Dispute Appeals Processing errors can be reviewed at Level II with a denial letter from the Level I review. Preauthorization or Medical Necessity Appeals Medicare Advantage will review the Level I case to determine if all requirements of the initial appeal have been satisfied. Additional documentation received from the provider will be forwarded to the Medical Director to review and confirm medical necessity. The provider will receive a favorable or unfavorable decision letter for each qualified Level II Appeal. Status of Appeal or Rebill Concern: Offices are being told not to call for a status of an appeal or rebill until 60 days after the request. BCBSM will review and respond to provider requests within 60 days from the time we receive notice. Timing for response is determined by BCBSM but directly aligns with that of Original Medicare. There are times that response may take longer due to systems issues. Multiple rebills by providers can further delay a response. Angela Bullock, Director - MA Clinical Oversight SYSTEM ISSUE RESOLUTION PROCESS 4

5 System Issue Process Improvement Medicare Plus Blue has been working internally to address outstanding provider issues and improve timeliness of resolution Provider Consultants and Provider Servicing remain best routes to ensure documentation, research and resolution of an issue or concern Issues are consolidated to one master log to reduce inconsistent messages to providers and delays to resolution Weekly internal cross-functional work groups and bi-weekly oversight from leadership promotes communication, transparency and accountability 13 System Issue Resolution Process System issues are often identified by servicing or consultants based on feedback or inquiries providers Inquiries are researched to determine if concern should be considered a defect or other issue (e.g. billing error, policy change) Internal workgroup manages all defects and other broad issues that cause denials or payment concerns on a log Issues are triaged for priority (Critical/High/Medium/Low) based on claims volume and dollar amount across all the impacted providers Monthly updates on known open issues impacting multiple providers posted on WebDENIS Updates on individual issues should be referred to Provider Consultants System Issue Resolution Stages Under Review In Progress Quantification Closed, Communicate Confirm issue has been resolved Release monthly Web- DENIS with issue status updates and weekly messages for claim adjustments Identify concern Triage with examples Escalate (policy or system concern) Write requirements Design change or fix Develop system or policy change Test changes Generate list of impacted claims Design plan for making adjustments including timing Seek approval for adjustments Notify providers as appropriate Make claim adjustments in system 5

6 Known Claims Issues Examples of critical and high priority issues currently being addressed that impact multiple providers Outpatient high tech radiology claims denying for missing prior auth when auth is present Claims denying when multiple authorizations are included on one claim Out of state claim adjustments are giving only one reason code on 835 in error Claims for J0881 and J0885 denying for dx code D64.81 Certain claims denying with wrong liability code - contractual obligation (CO) instead of patient responsibility (PR) Reversals or inaccuracies in copays for Rural Health Centers (RHCs) 835 recoupments are not appearing on payment vouchers Incorrect application of specialty vs. PCP member cost share applied Unable to verify authorizations for members after they terminate Adjustments for multiple surgeries is not being applied to bilateral procedures Challenges Resolution process still under continuous review for improvement Backlog of provider inquiries and written documentation submissions is improving but not fully resolved yet Claims system defects take time to resolve but BCBSM is working with its claims vendor to implement solutions to issues faster Complex issues require extensive research and input from numerous departments 6