Montgomery County Medical Society

Transcription

1 Montgomery County Medical Society CareFirst BlueCross BlueShield Presentation November 12, 2015 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

2 Agenda CareFirst Direct Verify/Update Provider Information Electronic Capabilities Medical Authorizations Cost Sharing - Total Care and Cost Improvement Initiative (TCCI) ICD-10 Update 2

3 CareFirst Direct CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

4 Login to CareFirst Direct 4

5 CareFirst Direct Free service View eligibility and benefit information View claim status, authorizations and referrals View remittances/notice of payment Avoid time-consuming phone calls Submit inquiries on your own time and receive a reference number View Fee Schedule Submit inpatient notifications and outpatient pre-authorizations Perform provider updates that will enable providers to keep their information current 5

6 Verify/Update Provider Information CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

7 View Your Provider Information 7

8 Verify/Update Permission It is important to note that if you do not have the permission to verify/update the provider information, then you will only be able to view the information. You will need to ask your Office Administrator to assign you the Provider Credentialing Updates role and follow the step by step guide provided in CareFirst Direct, as appropriate. 8

9 Electronic Capabilities CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

10 Electronic Capabilities CareFirst encourages the use of electronic capabilities to improve submission of claims, receipt of payment information, and faster receipt of payment: Submit claims electronically - For faster processing without the delays of regular mail - Eliminate incomplete submissions because claims are edited and returned at the front-end through your clearinghouse for correction and resubmission Automated posting of payments with Electronic Remittance Advice (835/ERA) - Automatically post payments to patient accounts - ERA/835 information can be accessed and viewed on CareFirst Direct Fast and secure receipt of payments with Electronic Funds Transfer (EFT) - Allows CareFirst to deposit monies directly into your bank account - Payments are received faster and in a safer environment For more information on how to avoid the use of paper claim forms, expedite your claims submission and receive your payments faster please visit our website at 10

11 Electronic Services Learn about electronic claims submission, electronic remittance advise (835/ERA), electronic fund transfer (EFT), errors, and much more Access electronic information from the landing page Select topic 11

12 EDI Support EDI Support Difficulties with submissions? Contact your vendor/clearinghouse first CareFirst: EDI Service Line For better assistance, use one of the following terms when placing your call: 835 ERA's/enrollment NPI 837 claim status for NCOF (no claim on file) or front end rejections from CareFirst 12

13 Medication Management Authorizations CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

14 Medication Management CareFirst has added a new Prior Authorization requirement for certain specialty medications administered in the outpatient department, home, or office settings. Our goal for these very high cost therapies is simply to promote the use of the right therapy, on the right patient, for the right indication, in the right place, at the right dose, and at the right time. CareFirst has delegated the processing for these Prior Authorizations to CVS Caremark. The majority of CareFirst members are impacted by this new requirement; therefore, as always, we recommend that a member's eligibility be verified when services are rendered. 14

15 Medication Management Members not currently impacted by this requirement: Federal Employee Program (FEP) BlueCard out-of-area members Third Party Administrator (TPA) network lease A prefix CareFirst Administrator (CFA) Medicare Supplemental and Secondary members when Medicare pays as primary* A separate authorization is not required if the medication is administered to a patient: As part of an inpatient hospital stay Who is in observation In the outpatient department during surgery In the emergency room Links to the Prior Authorization User Guide and Frequently Asked Questions can be found at > Provider News section. *Note: If Medicare denies the claim and CareFirst becomes primary then a Prior Authorization is required for any drugs on the list. 15

16 Medication Management How to Obtain a Prior Authorization These authorizations can be submitted: Online: Log in to the Provider Portal at > and click on the Pre- Auth/Notifications tab to begin your request.* These Prior Authorizations are to be entered as Drug not Medical. By Phone: Call (888) By Fax: Visit > Forms > Pharmacy Prior Authorization to download the appropriate Prior Authorization form. *Note: As a reminder, Maryland providers are required to submit Prior Authorization requests online (Maryland Code, Health General ). We highly encourage all network providers in our other jurisdictions (Washington, D.C. and Northern Virginia) to submit requests online as well for faster service. 16

17 Cost Sharing Total Care and Cost Improvement Initiative CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

18 Cost Sharing As a part of our Total Care and Cost Improvement (TCCI) Initiative, CareFirst has collaborated with several vendors to offer additional care coordination programs and specialized care services to support Primary Care Providers (PCPs) and specialists as they seek to improve cost and quality outcomes for their patients, our members. As of March 1, CareFirst began waiving cost share for professional services for certain members. These are members who are under care coordination in an active care plan. To support this initiative, we are offering a webinar titled Cost Share Waiver that explains what we are doing, why we are doing it, and to explain how you can identify affected members. Please go to to register for this webinar that explains our initiative. 18

19 TCCI Example 19

20 TCCI Patient costs have been waived if you see one of the following messages: 20

21 TCCI Patient costs have not been waived if you see one of the following messages: OR 21

22 CareFirst ICD-10 Update November 2015 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

23 ICD-10 has gone live! CareFirst successfully transitioned to ICD-10 on 10/1. We are enforcing the appropriate use of ICD-10 codes, as outlined in the CareFirst ICD-10 Claim Submission Guidelines document, available on our Provider Portal. CareFirst had three criteria for a successful ICD-10 transition: Receive claims successfully Adjudicate claims in a timely manner Support provider ICD-10 questions and issues 23

24 CareFirst is receiving claims successfully 10/1 Daily Claim Volume Long-Term 165 Average ICD-10 claim volume is overtaking ICD-9 volume As of now, ~84% of claims received use ICD-10 codes Claims volumes have decreased by 4% since October 1 st This decrease is smaller than expected, indicating strong provider readiness 0 9/28 10/5 10/12 10/19 10/26 11/2 CareFirst has not seen a significant increase in the rate of compliancedriven claim rejections ICD-10 Claim Volume ICD-9 Claim Volume Data as of Friday, 11/6 24

25 CareFirst is adjudicating claims successfully All of the CareFirst adjudication platforms are successfully processing and paying ICD-10 claims. Denials We have not seen any spike in aggregate claim denial rates Processing Automatic processing of claims has stayed high Pended claims are being processed within the contractual adjudication windows Pricing We have seen no significant shifts in pricing of claims - either increases or decreases 25

26 Support channels are ready to help with ICD-10 If you have any ICD-10 issues, providers do not need to reach out to a new point of contact. You should raise issues through your existing support channels: Provider Service Phone Numbers Provider Relations Representatives These support channels have been trained on ICD-10, and are able to resolve most ICD-10 related questions/issues. CareFirst has an ICD-10 Command Center that the support channels are linked to. If your issue can t be resolved immediately, it will be escalated internally to the Command Center ICD-10 subject matter experts for resolution. 26

27 CareFirst ICD-10 guidelines are available online CareFirst ICD-10 information is available on our Provider Portal, including: Provider FAQs ICD-10 Claims Submission Guidelines ICD-10 Authorization Request Guidelines Direct Link: 27

28 Any Questions? Thank You for Attending 28