Group Administrator s Manual. Table of Contents

Transcription

1 Group Administrator s Manual 1 Enrolling for Coverage Eligibility to Enroll 1.2 Group Forms 1.3 Enrolling for Coverage 1.3 Standard Enrollment Guidelines 1.4 Errors 1.5 Electronic Enrollment Options 1.6 Enrollment/Eligibility Electronic Solutions 1.7 Coverage Effective Dates 1.11 Termination of Coverage for Members 1.11 Specifics for Enrolling Members 1.12 Annual Enrollment Period 1.12 Social Security Numbers and Replacement Identification Numbers 1.13 Dependents 1.14 Alternate Address for Dependents 1.14 Common Law Marriages 1.15 Children through Age Domestic Partners 1.16 Disabled Dependents 1.17 Autism Spectrum Disorders 1.17 Ward Certification 1.18 Dependents on Medicare 1.18 Newborns and Adopted Children 1.19 Coverage for Children to Age Students 1.20 Members with Other Coverage 1.20 What if Someone Doesn t Want to Enroll? 1.21 keb/a2/8400/i.docx (9/2018)

2 ii Group Administrator s Manual Changing Enrollment Information 1.21 Updating Information Affecting Coordination of Benefits (COB) with Medicare 1.23 Annual Solicitation of Employer Size Information 1.23 What is a Life Status Change? 1.24 Retroactive Enrollments and Terminations 1.26 Group Termination 1.27 Changing Coverage to Medicare Complementary 1.27 What to Do If Your Group Hasn t Chosen a Medicare Complementary Product 1.29 Keeping Track of Your Members 1.29 PlusBilling Form 1.29 Age 65 Notification 1.30 COBRA Continuants 1.31 Disabled Dependent Certification 1.32 Overage Dependents 1.33 Student Dependent Verification 1.35 Act 83 (Extension of Health Insurance Benefits for Certain Military Personnel) 1.36 Employees No Longer Eligible for Coverage 1.37 Individual Plan (Nongroup) Enrollment 1.37 Employers May Not Pay Individual Premiums 1.38 Information about Enrollment Policies and Regulations 1.38 COBRA 1.38 Mini-COBRA 1.39 Healthcare Reform 1.40 Helping You Understand Healthcare Reform 1.40 Medical Loss Ratios 1.40 Rebates and Administrative Requirements 1.41 Collecting Employer Information 1.41 Retroactive Terminations 1.42 The Practical Effect 1.43 Employer Mandate 1.43 keb/a2/8400/ii.docx (9/2018)

3 Group Administrator s Manual iii Essential Health Benefits 1.43 Rate Calculation 1.44 Plan Mining Metal Levels 1.44 Women s Preventive Care Tax Forms 1.46 Subscriber/Member Termination Notification Letters 1.47 Medicare Secondary Payer (MSP) Laws 1.47 Provisions of the Medicare Secondary Payer Laws 1.47 Nondiscrimination 1.48 Prohibition on Financial Incentives 1.48 Coordination of Benefits Rules 1.48 The Working Aged Rule 1.49 The Disability Rule 1.50 The End-Stage Renal Disease (ESRD) Rule 1.50 Dual Eligibility Rules 1.51 Employer Size 1.52 Penalties for Noncompliance 1.52 Medicare Secondary Payer Demand Letters and CMS Recovery Process 1.52 Questions and Answers Concerning the Medicare Secondary Payer Laws 1.53 Requirements for Enrolling for Group Insurance 1.55 Checking Group Participation ID Cards and Products Capital BlueCross Health, Prescription Drug, Dental, and Vision Coverage One ID Card 2.2 What Changes Generate New ID Cards? 2.7 If There is a Mistake on the Card 2.8 To Obtain Additional ID Cards 2.9 keb/a2/8400/iii.docx (9/2018)

4 iv Group Administrator s Manual When an Employee Leaves 2.9 Capital BlueCross Portfolio of Group Products and Services 2.10 Preferred Provider Organization Programs 2.10 PPO 2.10 CareConnect Gatekeeper PPO 2.11 PPO Plus 2.13 Exclusive Provider Organization (EPO) Programs 2.15 Valley Advantage EPO 2.15 Traditional 2.16 Comprehensive 2.17 Capital BlueCross Consumer-Directed Health Plans 2.18 HSA or HRA? Which Plan is Right for Me? 2.19 Health Savings Account (HSA) 2.21 Health Reimbursement Arrangement (HRA) 2.22 Advantages of an HRA 2.22 Flexible Spending Account (FSA) 2.23 PPO Choice 2.25 POS 2.26 HMO 2.27 Prescription Coverage 2.28 Dental Coverage 2.30 BlueCross Dental 2.30 Pediatric Dental Coverage (for Small Groups only) 2.31 Vision Coverage 2.32 Pediatric Vision Coverage (for Small Groups only) 2.32 Programs for Medicare-Eligibles 2.33 Senior 2.33 BlueJourney HMO 2.34 BlueJourney PPO 2.36 Other Services 2.39 Medicare Part D Prescription Drug Coverage (PDP) 2.39 Blue Cross Blue Shield Global TM Health Plans 2.39 keb/a2/8400/iv.docx (9/2018)

5 Group Administrator s Manual v 3 Billing and Payment The PlusBilling System 3.3 Specific Billing Practices 3.4 Actual Effective Date/Split Month Billing 3.4 Newborn or Adopted Dependents 3.5 Death of a Member 3.5 Employer May Not Pay Premiums for Individual Coverage 3.5 PlusBilling for Groups 3.6 PlusBilling Member Statement 3.6 Billing for Large Groups 3.7 Self-Funded Arrangements 3.7 Healthcare Reform and Billing 3.7 The PlusBilling Form 3.8 Checking Your PlusBilling Statement 3.8 Methods of Payment 3.9 Adjustments to Your Bill 3.10 Nonpayment Notification 3.11 HSA/HRA Billing Provider Information Medical Product Networks 4.2 Specialty Networks and Management Services 4.3 Mental Health and Substance Abuse Medical Management 4.3 Chiropractic Providers 4.3 Physical and Occupational Therapy Utilization Management 4.4 Radiology Utilization Management 4.4 Blue Distinction Centers 4.4 Blue Distinction Centers for Bariatric Surgery 4.5 keb/a2/8400/v.docx (9/2018)

6 vi Group Administrator s Manual Blue Distinction Centers for Transplants 4.5 Blue Distinction Centers for Cancer Care 4.6 Blue Distinction Centers for Cardiac Care 4.6 Blue Distinction Centers for Knee and Hip Replacement 4.6 Blue Distinction Centers for Spine Surgery 4.6 Blue Distinction Centers for Maternity Care 4.7 National and Worldwide Network Access 4.7 BlueCard Urgent Care Benefits for HMO Members 4.7 Away From Home Care Guest Membership 4.8 Provider Contracting Information 4.8 How Can I Get My Doctor to Join the Network? 4.9 How Are Participating Providers Paid? 4.9 Capitation 4.9 Referrals 4.10 Pharmacy Network 4.11 Specialty Medications Covered Under the Medical Benefit 4.12 Dental and Vision Networks Obtaining Service and Filing Claims Claims and How They Work 5.2 Participating Providers 5.2 Important Information about EOBs 5.3 Nonparticipating Providers 5.4 Providers Outside the Capital BlueCross Network Area 5.5 Claim Forms 5.6 Filing a Medical Claim 5.8 What is an Itemized Bill? 5.9 Services Requiring Special Information 5.11 Special Situations 5.12 keb/a2/8400/vi.docx (9/2018)

7 Group Administrator s Manual vii What s the Difference between the Provider Responsibility and the Amount Paid by CBC? 5.13 What Happens if There s an Office Visit Copay with our Product? 5.14 What about a Product with Coinsurance? 5.15 What Happens if I Need an HMO or POS Referral? 5.15 What if an Employee Doesn t Live Here? Or, the Employee is on Vacation? 5.16 Finding BlueCard Participating Providers When Away From Home 5.17 Services from Nonparticipating Providers 5.18 Travel Outside the United States 5.18 Filing Claims for Out-of-Country Services 5.19 Inpatient Hospital Claims 5.19 Professional Provider Claims 5.20 International Claim Form 5.20 Prescription Drug Claims 5.20 Retail Service 5.22 Submitting a Retail Prescription Drug Claim 5.22 Prescription Drug Mail Service 5.24 Mail Service Refills 5.25 Specialty Medications 5.26 Accessing Prescription Drug Internet Services 5.27 International Prescription Drug Service 5.29 Dental Claims 5.30 Predetermination 5.31 Submitting Claims for Dental Services 5.31 Work in Progress Dental Claims 5.32 International Dental Claims 5.33 Vision Claims 5.33 Participating Vision Provider 5.33 Nonparticipating Vision Provider 5.34 International Vision Claims 5.34 Medicare Supplement Claims 5.35 keb/a2/8400/vii.docx (9/2018)

8 viii Group Administrator s Manual Other Party Liability 5.36 Coordination of Benefits (COB) 5.36 What Coverage is Primary (How is Primacy Determined) for Dependents Medical Claims? 5.37 Rules for Determining Primary Coverage 5.38 How Does Capital BlueCross Actually Coordinate Benefits? 5.40 Example of COB Claims 5.42 Questions Concerning a COB Claim? 5.48 Coordination of Benefits for Prescription Drug Claims 5.48 Coordination of Benefits for Dental Claims 5.48 Coordination of Benefits for Vision Claims 5.48 Subrogation 5.49 Subrogation of Medical Claims 5.49 Identifying Claims for Subrogation Investigation 5.49 Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL) 5.50 Workers Compensation 5.51 Third Party Liability Cases 5.51 Subrogation and Prescription Drug Claims 5.51 Subrogation for Dental Claims 5.52 Subrogation for Vision Claims 5.52 Appealing Claim Decisions 5.52 Start an Appeal 5.52 Document Requests 5.53 Appeal Guidelines 5.54 Internal Review Time Frames 5.55 External Review Process 5.55 Expedited Appeal Process for Claims Involving Urgent Care 5.56 Initial Determination for Claims Involving Urgent Services 5.56 Expedited Internal Appeal Process for Claims Involving Urgent Services 5.56 Expedited External Appeal Process for Claims Involving Urgent Services 5.56 keb/a2/8400/viii.docx (9/2018)

9 Group Administrator s Manual ix Complaint and Grievance Procedures POS and HMO 5.57 Grievance Process (for Grandfathered POS/HMO) 5.58 First Level Grievance Review 5.58 Second Level Grievance Review 5.58 External Grievance Review 5.58 Expedited Review Process (for Grandfathered POS/HMO) 5.59 Expedited Internal Review 5.59 Expedited External Review 5.59 Complaint Process (for All POS/HMO) 5.60 First Level Complaint 5.60 Second Level Review 5.60 External Review 5.60 Prescription Drug Appeal Guidelines 5.61 Dental Claim Appeals BlueCross Dental 5.61 Vision Claim Appeals To Appeal an Adverse Benefit Determination Working to Improve Your Employees Health Focusing on Member Health and Wellness 6.3 Live Healthy 6.3 Wellness 6.5 Health Assessment 6.5 Blue Health Seminar Live Healthy Workshop 6.6 Employer Tool Kit 6.7 Web Resources 6.7 Search & Save Center 6.7 Online Health Education Literature 6.8 Preventive Health Reminders 6.8 Health Education and Wellness Worksite Services 6.9 keb/a2/8400/ix.docx (9/2018)

10 x Group Administrator s Manual Biometric Screenings 6.10 Additional Program Components 6.11 Healthy Rewards 6.11 Virtual Services 6.12 Capital BlueCross Nurse Line 6.14 Disease/Condition Management 6.15 Disease and Condition Management for Adults, Pediatrics, and Seniors 6.15 Care Management 6.17 Case Management 6.17 Who Qualifies for Case Management Services? 6.17 The Case Manager 6.18 Precious Baby Prints 6.18 Emergency Room Outreach 6.19 Utilization Management Programs 6.20 Concurrent Review 6.20 Transition of Care Program 6.21 Discharge Planning 6.21 Preauthorization 6.21 Approach to Prescription Drugs 6.23 Formulary for Prescription Drugs 6.23 Prior Authorization for Prescription Drugs 6.24 Enhanced Prior Authorization (or Step Therapy) 6.25 Drug Quantity Management for Prescription Drugs 6.25 Generic Substitution Policy for Prescription Drugs 6.26 Benefit Exclusions/Limitations for Prescription Drugs 6.27 Utilization Review Program for Prescription Drugs 6.27 Drug Forms and Information HIPAA Privacy and Your Company keb/a2/8400/x.docx (9/2018)

11 Group Administrator s Manual xi HIPAA Privacy 7.2 HIPAA Notice of Privacy Practices 7.2 HIPAA Member Authorization Form to Release Information 7.2 HIPAA Privacy Group Certification Form 7.3 Business Associate Agreement 7.3 HIPAA Group Health Plan Representative Authorized to Receive Member Information Form Reference Phone Reference 8.2 Address Reference 8.3 Retail Locations 8.4 Internet 8.4 Find Information Online 8.5 keb/a2/8400/xi.docx (9/2018)

12 xii Group Administrator s Manual 9 Forms and Reports Request for Group Supplies (NF-69) 9.2 Appeals Form (NF-632) 9.3 Application to Enroll or Change Enrollment (NF-2) 9.6 Authorization of Designated Appeals Representative (ADAR) Form for Traditional/Indemnity Lines of Business (NF-631) 9.10 Billing and/or Enrollment Agent Form (C-483) 9.11 BlueCross Dental Appeal Procedures 9.12 BlueCross Dental Claim Form 9.14 BlueCross Vision Claim for Vision Care Expense Form (BCV-1) 9.15 Certification for Dependent Through Age 29 (F1/2268) 9.17 Claim Form (NF-43A) 9.18 Dependent Through Age 29 Recertification Letter (FLL1/391) 9.26 Disabled Certification Cover Letter (AA-COR-127) 9.28 Disabled Dependent Certification Form (C-33) 9.29 ecerts 9.31 Explanation of Benefits (EOB) Form 9.32 HIPAA Group Health Plan Representatives Authorized to Receive Member Information Form (PO-12) 9.34 HIPAA Member Authorization Form to Release Information (PO-9) 9.35 HIPAA Notice of Privacy Practices Brochure (PO-3) 9.38 HIPAA Privacy Group Certification Form (PO-10) 9.42 Ineligible Student Notification Letter (FLL1/219) 9.43 Ineligible Student Notification Letter (FLL1/148) (For Large Groups) 9.44 Mail Service Order Form (CVS-ENG) 9.45 Medicare Eligibility Notice (C-25) 9.47 Members Approaching Age 65 Report (CM-M-050) 9.50 Nondiscrimination and Foreign Language Assistance Notice (C-572) 9.51 keb/a2/8400/xii.docx (9/2018)

13 Group Administrator s Manual xiii Notification of Dependent Removal (FLL1/384) 9.52 Notification of Dependent Removal Through Age 29 (FLL1/380) 9.54 Notification to Insurer of Completion of Active Duty 9.55 Notification to Insurer of Placement on Active Duty 9.56 Notification to Insurer of Re-Enrollment as Full-Time Student 9.57 Other Party Liability Report 9.58 Overage Dependent Information Letter (CM-M-530) 9.60 Overage Dependent Terminations Report (CM-M-130) 9.62 Overage Notification Letter (Non-HMO) (CM-M-520) 9.63 Overage Notification Letter (HMO) (CM-M-520) 9.64 PlusBilling Form (NF-24) 9.65 PlusBilling Member Statement (CM-B-560) 9.70 Prescription Reimbursement Claim Form 9.80 Recertification Removal Notice for Dependent Through Age 29 (FLL1/378) 9.82 Reimbursement Voucher (C-387) 9.83 Request for Exception to Life Status Change Policy or for Retro Termination Exception (C-30) 9.84 Request for Recertification Notice (FLL1/379) 9.85 Reverification Removal Notice (FLL1/390) 9.86 Student Reverification Letter (FLL1/231) 9.87 Students Terminated from Reverification Process (CM-M-120) 9.89 Subscriber/Member Termination Notification (CM-M-5020/ CM-M-5010) 9.90 Subscriber Release for Direct Contact with Spouse/Adult Child (NF-25) 9.92 Waiver of Group Health Insurance Coverage (C-69) 9.93 Ward Certification Letter (Non-HMO) (FLL1/107) 9.94 Ward Certification Letter (HMO) (FLL1/107) 9.95 keb/a2/8400/xiii.docx (9/2018)

14 xiv Group Administrator s Manual At Your Service ***Shaded portions in chapters 1 through 8 apply only to large group customers such as fully-insured Experience-Rated Groups that have 100 or more enrolled subscribers, and large (100 or more) Administrative Services Only (ASO) Groups. keb/a2/8400/xiv.docx (9/2018)