Provider Manual Blue Cross and Blue Shield of Vermont and The Vermont Health Plan

Transcription

1 Provider Manual 2018 Blue Cross and Blue Shield of Vermont and The Vermont Health Plan

2 Table of Contents Provider Manual 2017 Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Section 1 Getting in Touch with BCBSVT and TVHP 1 Plan Definitions 2 Office Training and Orientation 3 Provider Participation and Contracting 3 Access Standards 10 Availability of Network Practitioners 11 Opening/Closing of Primary Care Provider Patient Panels 11 PCP Initiated Member Transfer 11 Transitioning Pediatric Patients 11 Notification of Change in Provider and/or Group Information 12 Utilization Management Denial Notices: Reviewer Availability 13 Complaint and Grievance Process 13 Health Insurance Portability and Accountability Act (HIPAA) Responsibilities 14 Member Rights and Responsibilities 15 Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices 15 Section 2 Blue Cross and Blue Shield of Vermont Website 16 i Section 3 Mandates 20 Member Accumulators 20 Member Eligibility 21 Member Confidential Communications: 21 Standard Confidential Communication: 22 Confidential Communication for Sexual Assault: 22 Member Identification Cards 22 Confidential Communication for Sexual Assault: 22 Member Identification Cards 22 Member Proof of Insurance 25 Section 4 Medical Utilization Management (Care Management) 27 Section 5 Quality Improvement (QI) Program 36 BCBSVT/TVHP Special Health Programs 37 Provider Selection Standards 39 Section 6 General Claim Information 42 When to Collect a Co payment 45 Member Confidential Communications 51 Claim Specific Guidelines 51 Claim Submission and Reimbursement Guidelines 57

3 Section 7 The BlueCard Program Makes Filing Claims Easy 69 How Does the BlueCard Program Work? 69 Claim Filing 74 Frequently Asked Questions 79 Glossary of BlueCard Program Terms 81 BlueCard Program Quick Tips 82 Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint Program: 83 Section 9 The Federal Employee Program (FEP): 88 Index

4 Section 1 Getting in Touch with BCBSVT and TVHP A customer service team specializing in provider issues is available to you, see the telephone directory link below. The lines are open weekdays from 7 a.m. until 6 p.m. Please have the following information available when you call: Your National Provider Identifier(s). Your patient s identification number, including the alpha prefix and suffix if applicable. BCBSVT & TVHP Telephone Directory Contact Us: By Mail PO Box 186, Montpelier, VT In Person 445 Industrial Lane, Montpelier, VT On The Web Our website, has a variety of services for providers and members. See section 2 for more information. Secure Messaging The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure. To comply, we use the services of Proofpoint to protect our and ensure all PHI remains confidential. When a BCBSVT/TVHP employee sends you an that contains PHI, Proofpoint detects the PHI and protects the . You will receive an notification that you have been sent a Proofpoint secure message. The notification tells you who the secure message is from and includes a link to retrieve the message. The first time you use the Proofpoint message service to retrieve a message, you must create a password. Thereafter, you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVT/TVHP . Please note Proofpoint secure messages are posted and available for 30 calendar days. If the message is not opened during that time, the message is removed and the sender notified. For more information about Proofpoint, visit: 1

5 Plan Definitions CBA Blue CBA Blue is a third-party administrator (TPA) owned by BCBSVT. Providers contract for CBA through BCBSVT. CBA Blue members have unique prefixes. A complete listing of prefixes for CBA Blue members is available on our provider website at under references/prefixes. Claims for CBA Blue members should be submitted to CBA Blue directly. Please contact CBA Blue directly with any customer service or claim processing related questions. Their contact information is available on our Contact Information for Provider listing on our provider website at under "contact us." Federal Employee Program (FEP) The Federal Employee Program (FEP) is a health care plan for government employees, retirees, and their dependents. It provides hospital, professional provider, mental health, substance abuse, dental and major medical coverage of medically necessary services and supplies. BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members. Members with FEP coverage have ID numbers that begin with alpha prefix R. Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO) Comprehensive: Comprehensive coverage has an annual deductible amount and coinsurance up to an annual out-of-pocket limit. It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers, necessary services provided by inpatient/outpatient facilities and home health agencies, ambulance services, durable medical equipment, medical supplies, mental health/substance abuse services, prescription drugs, physical therapy and private duty nursing. The provider network for Comprehensive coverage is the participating provider network. Vermont Freedom Plan (VFP): the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program. The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers. Patients may seek services from non-participating providers, but in most cases they will pay higher deductible and/or coinsurance amounts. The Vermont Freedom Plan provides coverage with no deductible for office visits, well-baby care, and physicals. This plan requires members to pay a deductible and/or co-payment. The provider network for the Vermont Freedom Plan is our preferred provider network (PPO). All plans have a prior approval requirement for select medical procedures, durable medical equipment and select prescription drugs. Vermont Blue 65 SM Medicare Supplemental Insurance (formerly Medi-Comp) Vermont Blue 65 (formerly Medi-Comp): is a supplement available to individuals who have Medicare Parts A and B coverage. Effective 1/1/2005, BCBSVT changed the name of its Medicare Supplemental plans from Medi-Comp I, II, III, A and C to Vermont Blue 65 Plans I, II, III, A and C. It helps pay co-payments and coinsurance for Medicare-approved services. In some cases, the individuals will have to pay for all or part of the health care services. Benefits are provided only for approved Medicare-eligible services provided on or after the effective date of coverage. BlueCard See BlueCard Section 7 for details New England Health Plan (NEHP) See BlueCard, Section 7, for details. The Vermont Health Plan (TVHP) The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont-based managed care organization offering a cost-effective, high-quality portfolio of managed care products. The Vermont Health Plan offers an HMO product, BlueCare, and a point-of-service plan, BlueCare Options. 2

6 TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member. Members must get prior approval for certain medical procedures, durable medical equipment and certain prescription drugs. They must also get prior approval for out-of-network services. Members must use network providers for mental health and substance abuse care. These services also require prior approval. BlueCare Access: Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits. BlueCare : A PCP within The Vermont Health Plan s network coordinates a member s health care. Members must get prior approval for certain services and prescription drugs. No out-of-network benefits are available without prior approval. BlueCare Options: A network PCP coordinates a member s health care, but members have the option of seeking care out of network at a lower benefit level (standard benefits). Standard benefits apply when members fail to get the Plan s approval to use non-network providers, (subject to the terms and conditions of the subscriber s contract). Members pay higher deductibles and coinsurance with standard benefits. If members receive care within the network or get appropriate prior approval, they receive a higher level of benefits (preferred benefits). Members with TVHP benefits can be identified by alpha prefix ZIE. Vermont Health Partnership (VHP) Members covered under Vermont Health Partnership select a network PCP. Members pay a co payment for services provided by their PCP's (except defined preventive care)as well as specialty office visits. VHP covers hospital care, emergency care, home health care, mental health and substance abuse treatment. Co-payments or deductibles may apply. Members must get prior approval for out-of-network care, certain medical procedures, durable medical equipment and certain prescription drugs. VHP offers two levels of benefits, preferred and standard. Members get preferred benefits when using VHP network providers, or when they get our prior approval to use out-of-network providers. Standard benefits are available for some out-of-network services, meaning higher out-of-pocket expenses for the member. Members must use network mental health and substance abuse care providers and must get prior approval. Members with VHP benefits can be identified by the alpha prefix ZIH. University of Vermont Open Access Plan SM University of Vermont Open Access Plan: This open access plan is based on our Vermont Health Partnership product. It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits. Please refer to Vermont Health Partnership definition for full details. Riders Riders amend subscriber contracts. They usually add coverage for services not included in the core benefits. Employer groups may purchase one or more riders. Examples include: Prescription Drugs Vision Examination Vision Materials Fourth Quarter carry-over of deductible Benefit Exclusion Rider Infertility Treatment Sterilization Non-covered Surgery Dental Care 3

7 Office Training and Orientation Your BCBSVT provider relations consultant can assist you in several ways. 4 Provider contracting information and interpretation On-site visits Provider and office staff education and training Information regarding BCBSVT policies, procedures, programs and services Information regarding electronic claims options Provider Participation and Contracting Providers contract with BCBSVT and/or TVHP either directly or through Physician Hospital Organizations (PHOs). If you contract with BCBSVT and/ or TVHP through a PHO or physician/hospital group, you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated. If you contract directly with BCBSV T/TVHP, you are given a copy of the contract signed by all parties at the time of its execution. Contracting Provider contracts define the obligations of all parties. Responsibilities include, but are not limited to: obligations relating to licensure, professional liability insurance, the delivery of medically necessary health care services, levels of care, rights to appeal, maintenance of written health records, compensation, confidentiality, the term of the contract, the procedure for renewal and termination and other contract issues. All parties affiliated are responsible for the terms and conditions set forth in that contract. Refer to your contract(s) to verify the BCBSVT and/ or TVHP products with which you participate. You may have separate contracts or amendments for participation in different BCBSVT and/or TVHP products such as Indemnity (fee-for-service), Federal Employee Program, Vermont Health Partnership or The Vermont Health Plan. Participation The following provider contracts are available: Indemnity (fee-for-service)/vermont Health Partnership A combined contract that includes participation in: Accountable Blue BlueCard (out-of-area) Program CBA Blue Federal Employee Program (excluding dental services) Medicare Supplemental Insurance (Vermont Blue 65, formerly Medi comp) Preferred Provider Organization (PPO) (Vermont Freedom Plan) Traditional Indemnity (Fee-for-Service) Plans (J Plan, Comprehensive and Vermont Freedom Plan) University of Vermont Open Access Vermont Health Partnership Any other program bearing the BCBS service marks The Vermont Health Plan Contract Contracts may be direct or through a contracted PHO Providers who are under contract with BCBSVT for TVHP, are "participating providers" or "in-network providers." These providers submit claims directly to us, and receive claim payments from us. Participating and network providers accept the Plan's allowed price as payment in full for covered services, and agree not to balance bill Plan members. TVHP members pay any copayments, deductibles and coinsurance amounts up to the allowed price, as well as any non-covered services.

8 Incentives for Participation Participation with the Plan offers the following advantages: Direct payment for all covered services offers predictable cash flow, and minimizes collection activities and bad debt exposure. Claims you submit are processed in a timely manner. We make available either electronic (PDF or 835 formats) or paper remittance advices which detail our payments, patient responsibilities, adjustments and/or denials. Electronic Fund Transfers (EFT)/direct deposit for payments. Please note: if you select EFT/direct deposit you will no longer receive a paper remittance advice. A PDF format remittance advice is available online to print or download, or the 835 transaction is also available. Members receiving services are provided with an Explanation of Benefits (EOB) statement identifying payments, deductible, coinsurance and copayment obligations, adjustments and denials. The member s EOB explains the provider s commitment to patients through participation with BCBSVT and/or TVHP. The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process, policy directives, verification of the patient s coverage and clarification of the subscriber s and provider s contract. Online and paper provider directories contain the name, gender, specialty, hospital and/or medical group affiliations, board certification, if the provider is accepting new patients, languages spoken by the provider and office locations of every eligible provider. These directories are available at no charge to current and potential members and employer groups. This information is also available to provider offices for references or referrals on our website at For more information on provider directories, refer to "Providers Listing in Member Directories" later in this section. Providers and their staff are given information on policies, procedures, and programs through informational mailings, newsletters, workshops and on-site visits by provider relations consultants. The Plan accepts electronically submitted claims in a HIPAA compliant format and provides advisory services for system eligibility. Automatic posting data is available to electronic submitters. Participating providers have around-the-clock access to the BCBSVT website at which provides claims status information, member eligibility, medical policies and copies of informative mailings. Definition of Network Provider BCBSVT/TVHP defines Primary Care Provider and Specialty Care Provider by the following: Primary Care Provider (PCP): The BCBSVT Quality Improvement Policy, PCP Selection Criteria Policy provides the complete details of the selection criteria. The policy is located on the secure provider portal at under BCBSVT Policies, then the Quality Improvement link. Or, you can call your provider relations consultant for a paper copy. A network provider "with members" in managed care health plans may select to manage their care. Providers are eligible to be PCPs if they have a specialty in family practice, internal medicine, general practice, pediatrics, geriatrics or naturopathy. Certain Advance Practice Registered Nurses (APRN) can carry a patient panel.* Specifically, the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy. In addition, the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider, family nurse practitioner, gerontological nurse practitioner or pediatric nurse practitioner. *APRN's cannot be primary care providers for New England Health Plan Members. Specialty Care Provider (SPC): A network provider who is not considered a primary care provider. 5

9 Enrollment of Providers To enroll, the group or individual must hold a contract with BCBSVT and/or TVHP or a designated entity, and the individual providers to be associated must be enrolled and credentialed. Enrollment The forms for enrolling are located on our provider website at under "Forms, Enrollment and Credentialing." There are two forms: The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF). Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form. If you are a mental health or substance abuse clinician, in addition to the forms mentioned above, you also need to complete and Area of Expertise Form. The PECF must be used for adding a new physician/provider to a practice (new or existing), opening or closing of patient panel, changing physician/provider's practicing location, termination* of a physician/provider from group and changing of a physician/provider's name. *Please note: We will accept an for termination of a provider, rather than the PECF. Please see details below in "Deleting/Terminating a Provider" section. The GPECF must be used for enrolling a new group practice, including independent providers in a private practice setting, or updating an existing group's information such as tax identification number, group billing national provider identifier (NPI), billing, physical or correspondence addresses and/or group name. Note: new groups/practices need to complete the GPECF and a PECF for each physician/provider that will be associated with that group/practice. Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above Independent physicians/providers need to complete both the PECF and GPECF for enrollment or changes. Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF, or of group practice changes (defined above), by using the GPECF. The Blueprint Payment Roster Template is not our source of record for these changes.. PLEASE NOTE: BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitioner s license. If this is the case, simply indicate on the Provider Enrollment Change Form pending for license number in Section 3, Provider Information. Upon your receipt of the license, immediately forward a copy by fax (802) ) or (providerfiles@ bcbsvt.com), or if you prefer, mail a copy to Network Management at BCBSVT, PO Box 186, Montpelier, VT Upon receipt of the Vermont State licensure, BCBSVT will continue the enrollment process. Please be aware the enrollment process cannot be fully completed until all paperwork is received. Enrollment of Locum Tenens You must complete a Provider Enrollment/Change form and indicate in Section 3, Locum Tenens who the provider is covering for and how long they will be covering. Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing. If the coverage is expected to exceed 6 months, credentialing paperwork must be filed. Locum Tenens are not marketed in directories and if in a primary care practice setting, cannot hold a direct patient panel. Provider Credentialing The first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application. We are providing high level details below, however for complete detailed instructions, please refer to the Provider Quick Reference Guide on the CAQH website. Providers should use to access their CAQH application. Practice managers should use to access the provider's CAQH application. If you encounter any issue using the CAQH website or have questions on the process, please contact the CAQH Provider Help Desk at (888) Providers Currently Affiliated with CAQH Log onto using your CAQH ID number Re-attest the information submitted is true and accurate to the best of your knowledge. Please note that malpractice insurance information must be up to date and attached electronically. Also, practice locations need to be updated to indicate the group that the provider is being enrolled in. If you do not have a global authorization, you will need to assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information. 6

10 2. Providers Not Yet Affiliated with CAQH CAQH has a self-registration process. Go to if you are the provider you are a practice manager, use to complete an initital registration form. The form will require the provider/practice to enter identifying information, including an address and NPI number. Once the initial registration form is completed and submitted, the provider/practice manager will immediately receive an with a new CAQH provider ID. Login to CAQH with the ID and create a unique username and password. Complete the online credentialing application; be sure to include copies of current medical license, malpractice insurance and, if applicable, Drug Enforcement Agency License. If you do not have a "global authorization", you will need to assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information. If a participating organization you wish to authorize does not appear, please contact that organization and ask to be added to their provider roster. Providers Without Internet Access Providers without Internet access must contact CAQH s Universal Credentialing DataSource Help Desk at (888) and request a CAQH application be mailed to you. You must complete the application and return to CAQH for entry at: ACS Health Care Solutions Attn: (CAQH) 4550 Victory Lane Indianapolis, IN or FAX (866) Please include copies of current medical license, malpractice insurance coverage and DEA certificate (if applicable). Assign BCBSVT as an authorized agent, allowing BCBSVT access to your credentialing information. Once authorization has been given and your application is complete, CAQH will provide notification and *Med Advantage will begin to process your application and primary source verify your credentialing information. If for some reason your primary source verification exceeds 60 days, you will be notified in writing of the status and every 30 days thereafter, until the credentialing process is complete. Upon completion of credentialing, you or your group practice will receive a confirmation of your assigned NPI, networks in which you re enrolled, and your effective date. *Med Advantage If you apply for credentialing through the BCBSVT/TVHP joint credentialing committee, primary source verification will be completed by our agent, the National Credentialing Verification Organization (NCVO) of Med Advantage. 7

11 Provider Listing in Member Directories All providers are marketed in the on line and paper provider directories, except those noted below: 8 Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members being directed to a hospital or a facility. Dentist who provide primary dental care only under a dental plan or rider Covering providers (e.g., locum tenens) Providers who do not provide care for members in a treatment setting (e.g., board-certified consultants) The following provider information is supplied in the directories: Name, including both first and last name of the physician or provider Gender Specialty, determined based on education and training, and when applicable, certifications held during the credentialing process. Providers may request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice. Approved lists of specialties and certificate categories from one of the below entities are accepted: American Board of Medical Specialties: American Midwifery Certification Board: American Nurses Association: American Osteopathic Association: The Royal College of Pathologists: The Royal College of Physicians: The College of Family Physicians of Canada: Hospital affiliations, admitting/attending privileges at listed hospitals Board certification, including a list of board certification categories as reported by the ABMS. Medical Group Affiliations, including a list of all medical groups with which the physician is affiliated. Acceptance of new patients Languages spoken by the physician Office location, including physical address and phone number of office locations Credentialing Policy: The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers, credentialing and re-credentialing criteria, verification process, quality review and credentialing committee review, acceptance to the network, ongoing monitoring, confidentiality and practitioner rights in the credentialing process. The policy is located on the secure provider portal at under BCBSVT Policies Quality Improvement. Or, call your provider relations consultant for a paper copy. Providers rights during the credentialing process: To receive information about the status of the credentialing application. Upon request, the credentialing coordinator will inform you of the status of your credentialing application and the anticipated committee review date. To review information submitted to support the credentialing/re-credentialing application. Upon request, you will have the opportunity to review non-peer protected information in the credentialing file during an agreed upon appointment time. The appointment time will be during regular business hours in the presence of the credentialing coordinator. To correct erroneous/inaccurate information. The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification. You have the right to correct erroneous information received from verification sources directly with the verifying source. You must respond to the Plan in writing to address any conflicting information provided on the application. We will review your response to ensure resolution of the discrepancy. We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria.

12 Facility Credentialing The BCBSVT Quality Improvement Policy, Facility Credentialing provides the complete details. The policy is located on the secure provider portal at under BCBSVT Policies Quality Improvement Or, call your provider relations consultant for a paper copy. Reimbursement We reimburse providers in one of two ways: Fee for Service: reimbursement for a service rendered, an amount paid to a provider based on the Plan s allowed price for the procedure code billed. Capitation: a set amount of money paid to a Primary Care Provider or PHO. The amount is expressed in units of per member per month (PMPM). It varies according to factors such as age and sex of the enrolled members. Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report. The report is mailed before the 20th business day of every month. Each product is issued a separate capitation detail report and check. The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM. Capitation is paid during the three-month grace period for individuals covered through the Exchange (prefix ZII). If the member is terminated at the end of the grace period, months two and three will be recovered. For full details on Grace Periods, see "Grace Period for Individuals Through the Exchange" in Section 6. We use two methods of payment: Paper Check: Providers, upon effective date of contract, are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system. 00: Providers can opt to receive electronic fund transfers (EFT)/direct deposit. Sign up for EFT/direct deposit is electronic and on the BCBSVT.com provider website. BCBSVT partners with Change Healthcare to offer this service. It is free and you do not have to submit claims or have a relationship with Change Healthcare* to receive the service. Simply click on the link, complete the form and Change Healthcare will be in contact with you to complete the process. When you sign up to receive EFT/direct depsoit you also commit to pick up your remits in an electronic format (either PDF or 835). The PDF versions of the remits are available on the Change Healthcare or BCBSVT websites. Thirty days after your first EFT/direct deposit payment, our paper remits will stop being mailed. Electronic remits remain available on the secure website for a 6-year period. (* formerly Emdeon). Provider Roles and Responsibilities Open Communication BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives. We do not penalize providers for discussing medically necessary or appropriate care with members. Conscientious Objections to the Provision of Services Providers are expected to discuss with members any conscientious objections he or she has to providing services, counseling or referrals. Follow-up and Self-care Providers must assure that members are informed of specific health care needs requiring follow-up and that members receive training in self care and other measures they may take to promote their own health. 9

13 Coordination of Care VHP and TVHP members select Primary Care Providers (PCPs), who are then responsible for coordinating the member's care. PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care. When a member is referred to a specialist or other provider, we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the member s status. We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services. This template is available on our provider website link under provider manual & reference guide, general information, communication form for behavioral health and primary care providers. Primary Care Provider Coordinates Care Except for self-referred benefits, in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP. The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation, determining the diagnosis, and recommending ongoing treatment for the patient. While none of our Plans (except the New England Health Plan) require referrals, we encourage members to coordinate all care through their PCPs. Specialty Provider Responsibilities Specialty providers are responsible for: Communicating findings surrounding a patient to the patient s PCP to ensure that the PCP is informed of the member s status Obtaining prior approval as appropriate. Continuity of Care BCBSVT and TVHP support continuity of care. We allow standing referrals to specialists for members with life threatening, degenerative or disabling conditions. A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan, accept the Plan s payment rates and adhere to the Plan s credentialing and performance requirements. A request for a specialist to act as his or her PCP must come from the patient, and our medical director must review and approve the request. Providers may contact the customer service unit to initiate a request for a standing referral. A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care, even if the provider is out of network, if the provider agrees to certain conditions. A new member with life threatening, disabling or degenerative conditions with an ongoing course of treatment with an out-of-network provider may see this provider for 60 days after enrollment or until accepted by a new provider. Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year), which substantially diminish the person s functional abilities. Our medical director must review and approve the request. 10

14 Confidentiality and Accuracy of Member Records Providers are required to: Maintain confidentiality of member-specific information from medical records and information received from other providers. This information may not be disclosed to third parties without written consent of the member. Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws, court orders or subpoenas. Unauthorized individuals must not have access to or alter patient records. Maintain the records and information in an accurate and timely manner, ensuring that members have timely access to their records. Abide by all federal and state laws regarding confidentiality and disclosure for mental health records, medical records, and other health and member information. Records must contain sufficient documentation that services were performed as billed on submitted claims. Providers are responsible for correct and accurate billing, including proper use as defined in the current manuals: AMA Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS), and most recent International Classification of Diseases Clinical Modification (currently, ICD 10 CM). Access to Facilities and Maintenance of Records for Audits BCBSVT and TVHP (as the managed care organization), their providers, contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members, and any additional relevant information that may be required for auditing purposes. Medical Record Audits may include the review of financial records, contracts, medical records, and patient care documentation to assess quality of care, credentialing and utilization. Advanced Benefit Determinations Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to "Advanced Benefit Determinations". This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage. Refer to Section 4 - Advanced Benefit Determination, for further information. Prior Approval/Referral Authorization Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered, even if a BCBSVT/TVHP policy is secondary to Medicare. For more information on services requiring Prior Approval or referral authorizations, please refer to Section 4. Billing of Members Covered Services: Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services. Providers will not bill members for amounts other than applicable co-payments, coinsurance or deductibles. We encourage providers to use their remittance advices to determine member liability, for collection of deductibles and coinsurance, and to bill members. Copayments, deductibles and coinsurance, however, can be billed to the member at the point of service, prior to rendering of service(s). In order to bill for these liabilities, providers must call our Customer Service Department to ensure the correct collection amount. If after receipt of the remittance advice the member liabilities are reduced, the provider must provide a quick turn-around in refunding the member any amounts due. Non-Covered Services: In certain circumstances, a provider may bill the member for non-covered services. In these cases, the collection should occur after you receive the remittance advice which reports the service as non-covered and shows the amount due from the member. We require that you explain the cost of a non-covered service to the member and get the member s signature on an acknowledgement form, before you provide non-covered services. To verify that a service is covered, contact the appropriate customer service center. 11

15 Missed Appointments: The provider must post or have available to patients the office policy on missed appointments. If a member does not comply with the requirement and there is a financial penalty, the member may be billed directly. A claim should not be submitted to BCBSVT. Supporting documentation related to the incident needs to be noted in the members medical records. Services where Medicare is primary, but provider (1) does not participate/accept assignment and (2) is contracted with BCBSVT: Providers must adhere to the guidelines described in this section on "covered services" and/or "non-covered services". Providers will submit the claims directly to Medicare on behalf of the member. As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS), the claim will cross over directly for processing through the BCBSVT system. A remittance advice and any eligible payments will be made directly to the provider. Providers may collect from the member any payments Medicare made directly to the member as well as any member liabilities not collected at the point of service. The FEP program does not participate in the COBA program. The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or assist the member with the submission of the claim and EOMB to BCBSVT. See Section 6, "Providers who do not accept Medicare Assignment and are contracted with BCBSVT" for the details of how we price and process the claim. Waivers Services or items provided by a contracted/network provider that are considered by BCBSVT to be Investigational, Experimental or not Medically Necessary (as those terms are defined in the member's certificate of coverage) may be billed to the patient if the following steps occur: 1. The provider has a reasonable belief that the service or item is Investigational, Experimental or not Medically Necessary because: (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA-compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational, Experimental or not Medically Necessary; or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval; or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational, Experimental or not Medically Necessary. 2. Clear communication with the patient has occurred. This can be face to face or over the phone, but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible. The complete cost of the service has been disclosed to the member along with any payment requirements; and 3. A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered. The waiver needs to clearly identify all costs that will be the responsibility of the member, once signed, the waiver must be placed in the member s medical records. 4. Unless the member chooses otherwise, a claim for the service or item must be submitted to BCBSVT. This allows the member to have a record of processing for his/her files, and if he/she has an HSA or some type of health care spending account, to file a claim. After Hours Phone Coverage BCBSVT/TVHP requires that primary care providers (i.e., internal medicine, general practice, family practice, pediatricians, naturopaths, qualifying nurse practitioners) and OBGYNs provide 24-hour, seven day a week access to members by means of an on-call or referral system. Integral to ensuring 24 hour coverage is members ability to contact their primary care provider and/or OBGYN after regular business hours, including lunch or other breaks during the day. After-hours telephone calls from members regarding urgent problems must be returned in a reasonable time, not to exceed two hours. Accessibility of Services and Provider Administrative Service Standards: The BCBSVT Quality Improvement Policy, Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition, policy, methodology for analyzing practitioner performance and reporting. The policy is located on the secure provider portal at under BCBSVT Policies, then the Quality Improvement link. Or, you can call your provider consultant for a paper copy. 12

16 Compliance Monitoring BCBSVT/TVHP monitors access to after-hours care through periodic audits. The plan places calls to providers' offices to verify acceptable afterhours practices are in place. The Plan will contact providers not in compliance and will work with them to develop plans of corrective action. Reporting of Fraudulent Activity If you suspect fraudulent activity is occurring, you need to report it to the fraud hotline at (800) Calls to the hotline are confidential. Each call to the hotline is investigated and tracked for an accurate outcome. BCBSVT Audit The complete Audit, Sampling and Extrapolation Policy is available on our provider website at Here is a high level overview: For the purpose of the audit investigation, the contemporaneous records will be the basis for the Plan's determination. If the provider modifies the medical record later, it will not affect the audit results. Audit findings are based on documentation available at the time of the audit. Audit findings will not be modified by entry of additional information subsequent to initiation of the audit, for example to support a higher level of coding. Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (e.g. patient intake form, lab/radiology reports). The Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in Plan policies, provider contracts or provider manual. If an audit identifies instances of non-compliance with this payment policy, the Plan reserves the right to recoup all non-compliant payments. Provider Initiated Audit Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated. The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit, such as when it will take place, the information required, and the required formatting of documents. Access Standards Primary Care and OBGYN Services BCBSVT/TVHP include the specialties of general practice, family practice, internal medicine and pediatrics in their definitions of Primary Care Providers. BCBSVT/TVHP monitors compliance with the standards described below. We use member complaints, disenrollments, appeals, member satisfaction surveys and after-hours telephone surveys to monitor compliance. If a provider does not meet one of the below listed standards, we will work with the provider to develop and implement an improvement plan. The following standards for access apply to care provided in an office setting: Access to medical care must be provided 24 hours a day, seven days a week. Appointments for routine preventive examinations, such as health maintenance exams, must be available within 90 days with the first available provider in a group practice. Appointments for routine primary care (primary care for non-urgent symptomatic conditions) must be available within two weeks. Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of sufficient severity, including severe pain, that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in: placing the member s physical or mental health in serious jeopardy; or serious impairment to bodily functions; or serious dysfunction of any bodily organ or part). Appointments for non-urgent care needs, a member must be seen within two weeks of a request (excluding routine preventive care). Emergency care must be available immediately. Routine laboratory and other routine care must be available within 30 days. 13

17 If a provider does not meet one of the above standards, we work with the provider to develop and implement a plan of correction. The BCBSVT/TVHP administrative services standards for PCP and OB/GYN offices are as follows: Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment. If wait is expected to exceed 15 minutes beyond the scheduled appointment, the office notifies the patient and offers to schedule an alternate appointment. Waiting to get a routine prescription renewal (paper or call in to patient s pharmacy) shall not exceed three days. Call back to patient for a non-urgent problem shall not exceed 24 hours. Specialty Care Services BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians). The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialists compliance with the standards described below. We use member complaints, disenrollments, appeals, member satisfaction surveys and after hours telephone surveys to monitor compliance. The following standards for access apply to care provided in an office setting: Appointments for non-urgent symptomatic office visits must be available within two weeks. Appointments for emergency care (i.e., for accidental injury or a medical emergency) must be available immediately in the provider's office or referred to an emergency facility. If a provider does not meet one of the above standards, we work with the provider to develop and implement an improvement plan. Availability of Network Practitioners The BCBSVT Quality Improvement Policy, Availability of Network Practitioners provides the definition of the policy, including geographic access, performance goals, travel time specifications, number of practitioners, linguistic and cultural needs and preferences and how the program is monitored. The policy is located on the secure provider portal at com under BCBSVT Policies Quality Improvement. Or, you can call your provider consultant for a paper copy. Opening/Closing of Primary Care Provider Patient Panels Primary Care Services Opening of a Closed Physician Panel: A PCP may open his or her patient panel by sending a completed Provider Enrollment/Change Form (PECF). If opening your patient panel, be sure to include the date you wish to open your panel, otherwise, we will use the date we received the form. Closing of an Open Physician Panel: BCBSVT and TVHP require 60 day's notice to close a patient panel. You must submit a Provider Enrollment/ Change Form. The effective date will be 60 days from our receipt of the form. BCBSVT and/or TVHP will send confirmation of our receipt of your request, including the effective date of the change. A PCP may not close his or her panel to BCBSVT/TVHP members unless the panel is closed to all new patients. PCPs with closed patient panels: It is the PCP s responsibility to review the monthly managed care membership report. If a member appears as an addition and is not an existing patient, notify your provider relations consultant immediately. The notification should contain the member ID number and name. We will notify the member and ask him or her to select a new PCP. If notification from the PCP does not occur within 30 days, the PCP will be expected to provide health care until the member is removed from the provider s patient panel. We will send confirmation to the provider that the member has been removed and the effective date. 14

18 PCP Initiated Member Transfer A Primary Care Provider may request to remove a BCBSVT, TVHP and/or NEHP member from his or her practice due to: Repeated failure to pay co-payments, deductibles or other out-of-pocket costs. Repeated missed scheduled appointments. Rude behavior or verbal abuse of office staff. Repeated and inappropriate requests for prior approval; or Irreconcilable deterioration of the physician/patient relationship. The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patient/physician relationship, and any steps that have been taken to resolve this problem. The PCP should mail the letter to: Attn: (your provider relations consultant s name) BCBSVT/TVHP PO Box 186 Montpelier, VT The provider relations consultant and the director of provider relations will review each case, considering provider and member rights and responsibilities. If the transfer is approved, we will send a letter to the member with a copy to the PCP. The member will be instructed to select a new PCP who is not in the current PCP s office. The current PCP is expected to provide health care to the departing patient, as medically necessary, until the new PCP selection becomes effective. If we do not approve the transfer, we send the PCP a letter of explanation. Transitioning Pediatric Patients We know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue. We offer the following advice and tools to assist you: Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP). Help them to take the next step by recommending several providers. You may even be able to provide some inisght into who may be a good fit for them. Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients. To access the Find a Doctor tool, go to the Blue Cross and Blue Shield of Vermont website at and select the Find a Doctor link. Once you accept the terms you can search by name, location, specialty or specific gender of provider. Send a letter to your patients with a list of PCPs accepting new patients. We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process. This template is available on our provider website at com. Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile. We also offer an online option they can use to update their PCP by logging into our secure member portal at 15

19 Notification of Change in Provider and/or Group Information Please complete a Provider Enrollment/Change Form (PECF) for each of the following changes: Patient panel change (for managed care providers only) Physical, mailing or correspondence address Termination of a provider. In place of a PECF, we will accept an for termination of a provider. Please see details below in "Deleting/Terminating a Provider" section. Provider name (include copy of new license with new name) Provider specialty Change in rendering national provider identification number Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changes: Tax identification number (include updated W-9) Billing national provider identifier Physical, mailing or correspondence address Group Name Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating. We cannot accept requests for changes by telephone. If you have a change that is not on the list above, please provide written notification on practice letterhead. Include to BCBSVT and/or TVHP the full names and NPI numbers for the group and all providers affected by the change. The forms (PECF, GPECF and Area of Expertise) are available on our provider website at under Forms, Enrollment and Credentialing. If you are not able to access the web, contact provider enrollment at (888) , option 2, and a supply will be mailed to you. Mail your request to: Provider File Specialist BCBSVT PO Box 186 Montpelier, VT Or fax to: (802) We appreciate your assistance in keeping our records and provider directories up to date. Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up-to-date directory information. Note: Directory updates will occur within 30 calendar days of receipt of notice of change. Taxpayer Identification Number If your Taxpayer Identification Number changes, you must provide a copy of your updated W-9. We may need to update your provider contract if your W-9 changes. For more information, please contact your provider relations consultant at (888)

20 Provider Going on Sabbatical Providers going on sabbatical for an indefinite time period should suspend their network status. Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return. During the sabbatical time period, the provider will not be marketed in any directories and will have members temporarily reassigned to another in-plan provider if a covering provider within their own practice is not identified. Recredentialing will occur during the providers normal recredentialing cycle. The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely. If recredentialing is not timely, the provider risks network termination. Adding a Provider to a Group Vendor Providers joining a group vendor must provide advance notice to BCBSVT and/or TVHP. If the provider does not have an active National Provider Identifier with BCBSVT/TVHP, we need the following documents before we can add the provider: Provider Enrollment Change Form (PECF) Copy of current state licensure Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business must be supplied when dispensing and/or storing medications in that location.) Any applicable board certification Copy of liability insurance Credentialing via the CAQH process. (Please see Enrollment of Providers). Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form. When we receive the required documentation, we will activate your provider profile for both BCBSVT and TVHP. We will send a letter notifying the provider of his or her addition to the group vendor file. The letter will clarify the provider s status with each network, and the effective date. Provider Enrollment Change and/or Area of Expertise Forms are available on our provider website at under Forms, Enrollment and Credentialing. If you are not able to access the web, contact provider enrollment at (888) , option 2, and a supply will be mailed to you. Deleting/Terminating a Provider A provider who leaves a group or private practice must provide advance notice to BCBSVT. Notice can be provided through to providerfiles@bcbsvt.com or by completing the "terminate provider" section of the Provider Enrollment and Change Form (PECF). If you are sending through , be sure to include the provider's full name; rendering national provider identifier (NPI), and if in a group setting, the NPI of the billing group; the reason for termination (such as moved out of state, went to another practice, going into private practice, etc.) and the termination date. If the terminating provider is a primary care provider, we will need to know if there is another provider taking on those patients. If submitting a PECF, follow the instructions on the form. We appreciate your help in keeping our records up to date. Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVT/TVHP members. BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination. You can download a Provider Enrollment/Change Form by logging onto our provider site at If you do not have internet access, please contact your provider relations consultant for a copy of the form. 17

21 Utilization Management Denial Notices: Reviewer Availability We notify providers of utilization management (UM) denials by letter. Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer. All UM denial letters include the telephone number of our integrated health department. Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist. The telephone number is (option 3) or Complaint and Grievance Process Provider-on-Behalf-of-Member Appeal Process An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as: non-covered services pursuant to the Member Certificate; services are not medically necessary or investigational; lack of eligibility; or reduction of benefits. Before a provider-on-behalf-of member appeal is submitted, we recommend you contact the BCBSVT Customer Service Department, as most issues can be resolved without an appeal. If you proceed with an Appeal, there are three levels to the Provider-on-behalf-of-Member Appeal process. Level 1 A First Level Provider-on-Behalf-of-Member Appeal: A first level Provider-on-Behalf-of-Member Appeal must be filed in writing to: Blue Cross and Blue Shield of Vermont Attn: Appeals P.O. Box 186 Montpelier, VT The appeal request may also be faxed to (802) , Attn: Appeals. The appeal request should include all supporting clinical information* along with the Member certificate number, Member name, date of service in question (if applicable), and the reason for appeal. Assuming you have provided all information necessary to decide your grievance, the appeal will be decided within the time frames shown below, based on the type of service that is the subject of your appeal (grievance): *Note: You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT. All medical notes, etc., supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT. Grievances related to urgent concurrent services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty-four (24) hours of receipt; Grievances related to urgent services that have not yet been provided will be decided within seventy-two (72) hours of receipt; Grievances related to non-urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided within seventy-two (72) hours of receipt; Grievances related to non-urgent services that have not yet been provided (other than mental health and substance abuse services and prescription drugs) will be decided within thirty (30) days of receipt; and Grievances related to services that have already been provided will be decided within sixty (60) days of receipt. If the Provider-on-Behalf-of-Member Appeal is urgent, as described above, you and the member will be notified by telephone and in writing of the outcome. If the appeal is not urgent, as described above, you and the member will be notified in writing of the outcome. If you are not satisfied with the First Level Appeal decision, you may pursue the options below, if applicable. Level 2 Voluntary Second Level Appeal (not applicable to non group): A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice. If we have denied your request to cover a health care service, in whole or in part, you as the provider on behalf of member, may request a Voluntary 18

22 Second Level Appeal at no cost to you or the member. Level 1 outlines the information that should be included with your appeal, review time frames, and where the appeal should be sent. You and the member or the member s authorized representative have the opportunity to participate in a telephone meeting or an in person meeting with the reviewer(s) for your second level appeal, if you wish. If the scheduled meeting date does not work for you or the member, you may request that the meeting be postponed and rescheduled. Level 3 Independent External Appeal: A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking, Insurance, Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice. If you wish to extend coverage for ongoing treatment for urgent care services ( urgent concurrent services) without interruption beyond what we have approved, you must request the review within twenty four (24) hours after you receive our first level or voluntary second level denial notice. To make a request, contact the Vermont Department of Banking, Insurance, Securities and Health Care Administration during business hours (7:45 a.m. to 4:30 p.m., EST, Monday through Friday) at External Appeals Program, Vermont Department of Banking, Insurance, Securities and Health Care Administration, 89 Main Street, Montpelier, VT , telephone: (800) (tollfree). If your request is urgent or an emergency, you may call twenty-four (24) hours a day, seven (7) days a week, including holidays. A recording will tell you how to reach the person on call. If your request is not urgent, the Department will provide you with a form to submit your request. BlueCard Member Claim Appeal An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resources/forms/bluecard Claim Appeal. If the form is not submitted, the request will not be considered an Appeal. The request will not be filed with the home plan but rather returned to you. You will be informed of the decision in writing from BCBSVT. Please note, the form requires the member s consent prior to submission. Some Blue Plans may also require the member to sign an additional form, specific to their Plan, before starting the appeal process. When a Member Has to Pay If a member s appeal is denied, they must pay for services we don t cover. Health Insurance Portability and Accountability Act (HIPAA) Responsibilities BCBSVT, TVHP, and its contracted providers are each individually considered Covered Entities under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA-AS) issued by the U.S. Department of Health and Human Services (45 C.F.R. Parts ). BCBSVT, TVHP and contracted providers shall, by the compliance date of each of the HIPAA-AS regulations, have implemented the necessary policies and procedures to comply. For the purposes of this Section, the terms Business Associate, Covered Entity, Health Care Operations, Payment, and Protected Health Information have the same meaning as in 45 C.F.R. 160 and 164. Disclosure of Protected Health Information From time to time, BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT and/ or TVHP Payment and Health Care Operations functions, including but not limited to the collection of HEDIS data. Upon receipt of the request, the provider shall disclose, or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVT/TVHP as permitted by the HIPAA-AS at The provider is not required to disclose Protected Health Information unless A: BCBSVT and/or TVHP has or had a relationship with the individual who is the subject of such information; and B: The Protected Health Information pertains to that relationship; and 19

23 C: The disclosure is for the purposes of: The Payment activities of BCBSVT and/or TVHP Conducting quality assessment or quality improvement activities, including outcomes evaluation and development of clinical guidelines Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting health care providers and patients with information about treatment alternatives, and related activities that do not include treatment Reviewing competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance Accreditation, certification, licensing, or credentialing activities BCBSVT and/or TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure. Business Associates Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate, including, but not limited to, a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT and/or TVHP. The notice to BCBSVT/TVHP regarding such agreement shall, at a minimum, include: the name of the Business Associate the address of the Business Associate the address to which the BCBSVT and/or TVHP should remit payment (if different from the Provider s office) the contact person, if applicable Upon receipt of notice, BCBSVT and/or TVHP will communicate directly with Business Associate regarding Payment due to Provider. Provider must notify BCBSVT and/or TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement. BCBSVT/TVHP shall not be liable for payment remitted to Provider s Business Associate prior to receipt of such notification. Notifications should be sent to: Blue Cross and Blue Shield of Vermont Attn: Privacy Officer PO Box 186 Montpelier, VT Standard Transactions The provider and BCBSVT/TVHP shall exchange electronic transactions in the standard format required by HIPAA-AS. Questions regarding the status of HIPAA Transactions with BCBSVT/TVHP should be directed to the E-Commerce Support Team at (800) Member Rights and Responsibilities Click here for full details and link to the URL: Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices We are required by law to maintain the privacy of our members health information by using or disclosing it only with the member s authorization or as otherwise allowed by law. Members have the right to information about our privacy practices. A complete copy of our Notice of Privacy Practices is available at or to request a paper copy, contact the Provider Relations Department at (888)

24 Section 2 Blue Cross and Blue Shield of Vermont Website The Blue Cross and Blue Shield of Vermont (BCBSVT) website located at uses (128- bit encryption as well as firewalls with built-in intrusion detection software. In addition we maintain security logs that include security events and administrative activity. These logs are reviewed daily). Our provider website has a general area that anyone can access, and a secure area that only registered users can access. The general area of the provider website contains information about doing business with BCBSVT, such as recent provider mailings, news from BCBSVT, forms, medical policies, provider manual, tools and resources. The secure area of the provider website contains information such as eligibility, benefits and claim status for BCBSVT, FEP and BlueCard members. To become a registered user, you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to adding/deleting staff and assigning roles and responsibilities for your organization). If your organization does not already have a local administrator, click on the secure area of the provider website and follow the instructions to register as a new user. We have a Provider Resource Center Reference Guide available on our website at under the link Provider Manual & Reference Guides. This guide provides information on how to create an account, maintain users and use the eligibility, claim look-up, ClearClaim Connect and on line prior approval functionality. Questions related to the website can be directed to the provider relations team at (888) How to Review Coverage History on the Web: The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage for members for up to 18 months, as long as the member is still on an active BCBSVT policy. history If a member is terminated with BCBSVT, you will not be able to locate any eligiblity information on the web. There are two ways to review previous membership. If you know a member had previous coverage and is still active, you can complete a search using either ID or name and change the As of date to the date of coverage you are looking for: 21

25 This will bring you to that member selection or a list of members. Click on the member you want to review (by clicking on their name highlighted in blue): This will provide the details of the policy active during that time period. If you scroll to the bottom (titled Benefit Plan Information), you will see the effective dates of that specific policy: 22

26 Or the second option. If you do not know whether the member had previous coverage: Enter the member s identification number or name using the Eligibility/Benefits link. It will automatically default to the current date:: Depending on how you search, you will either get a list or that specific member. Click on the member s name (highlighted in blue). This will bring you to the page below: 23

27 Click on View History, which will give you a listing of previous dates of coverage (if applicable). If you want the specific details of the coverage and benefits, go back to the elligibility look up and change the As of date for the member. 24

28 Section 3 Mandates Administrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types. Below are some examples: Services provided by Athletic Trainers Autism Services Services provided by Chiropractors Services provided by Naturopaths You should always verify a members benefits prior to rendering services. As a reminder: When calling customer service team for eligibility, make sure you identify the type of provider who will be rendering the service, even if you think it is obvious. When using the provider resource center for eligibility verification: Athletic Trainers and Naturopaths: Before the Eligibility Detail look for the following message: NOTE: this plan provides no benefits for services performed by an athletic trainer or naturopath. Autism Services: Coverage information is contained within the member s certificate of coverage, which is located as a link after the eligibility verification. Chiropractic Services: Chiropractic benefit information will not appear in the eligibility verification. Member Accumulators Members have specific dates when their deductibles, out of pocket limits and other totals begin to accumulate. They then run for a 12-month period before resetting. Our member accumulators can be either on a calendar year or plan year. On a calendar year schedule, the deductible and other benefit totals start to accumulate on January 1, regardless of enrollment or renewal date. On a plan year schedule, the deductible and other benefit totals start to accumulate on the effective or renewal date, which can be any time of the year. They reset annually on the renewal date. Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases, benefits may be limited to only certain products): Deductibles Out-of-pocket maximums Physical medicine, occupational therapy and/or speech therapy limits Chiropractic visit limit (before we require prior approval) Nutritional counseling visit limits Annual vision exam eligibility (if the member has the benefit) Private duty nursing Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non-group) or ZIG (small group) are based on a calendar year. Large group employers have the option to select a calendar or plan year accumulators, so they will vary. It s very important when verifying eligibility that you verify when the members accumulators begin and reset. 25

29 Member Eligibility Member eligiblity can be verified by using our Provider Resource Center located at You must have a user name and password to view the information. Full details on requirements and how to obtain a password are available on the log in page. There are two web-based options available: Eligibility Search, and Realtime Eligibility Search. The Eligibility Search feature provides information on members covered by BCBSVT. The Realtime Eligibility Search provides information on all Blue Plan members, including BCBSVT and Federal Employee Program members. Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual. Please note: BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups. During this transition, you may find that the Group Number listed on a member s identification card is not the same number that appears during an on-line eligibility look up or a HIPAA compliant 270/271 transaction. When billing BCBSVT, you can report either number. BCBSVT does not use this information when validating the member s coverage or eligibility for claim processing. We anticipate the issue will be corrected in mid We also have customer service teams that can assist you over the phone if you are not able to utilize the webbased searches. Click here for a listing of contacts and number(s) to call for assistance. Regardless of which method you use to verify member eligibility, you will need to have key information available: 26 Patient Name (first and last) Patient Date of Birth (month, day and year) Patient identification number. BCBSVT members have an alpha prefix* consisting of three letters, plus nine digiits, starting with an 8. FEP members have the letter R as their prefix, followed by eight digits. BlueCard members have a 3-letter prefix followed by an ID code. These codes are of varying lengths and may consist of all numerals, all letters, or a combination of both. For a real time search in our provider resource center, some additional information is required: Subscriber Name (first and last) Subscriber Date of Birth (month, day and year) Requesting Provider (name or NPI#) *Alpha prefixes are not Blue Plan specific. For a listing of BCBSVT, NEHP and CBA Blue prefixes, click here. Member Certificate Exclusions Our members certificates of coverage and riders contain a section on general exclusions, which are services that, even if medically necessary, are not eligible for reimbursement. Included among these general exclusions are services prescribed or provided by a: Provider that we do not approve for the given service or who is not defined in our Definitions section as a provider Professional who provides services as part of his or her education or training program Member of your immediate family or yourself Veterans Administration Facility treating a service-connected disability Non-Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract If you have questions regarding benefit exclusions, please contact our customer service department, or your provider relations consultant. Member Confidential Communications: At times, our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner. For these situations, Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process.

30 The below processes only apply to BCBSVT and Vermont Health Plan members. Members of any other Blue Plan need to have requests filed with their home plans. There are two types of confidential communication process: Standard Confidential Communication Confidential Communication for Sexual Assault (or other expedited matters). Standard Confidential Communication: The member uses a Form F14: Confidential Communication Request. A copy of the form is available on our website at Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) or mailed to the attention of the privacy officer, BCBSVT, PO Box 186, Montpelier, VT or faxed to our Customer Service department (802) The requests will be reviewed and processed within 30 days. Confidential Communication for Sexual Assault: At times, Vermont S.A.N.E. (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims. The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form. These requests can be submitted using Form F14: Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form. If you are using Form F14, please clearly note that it is related to sexual assault. Forms can be faxed to the Legal Department (866) or the Customer Service department (802) It is very important to include on the form or the fax cover sheet a contact person s name and direct phone number for BCBSVT to follow up with questions or status on processing the request. Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims* don t get submitted and processed before BCBSVT gets the member s explanation of benefits re-directed or member resource center access revoked. *Facilities and/or providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted. For these expedited cases, the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted. Member Identification Cards Blue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members. Providers should periodically ask to see the member s identification card, and keep a photocopy of it on file. Important information is often printed on the back of the card, and in some cases, failure to comply with requirements described on the card may result in a reduction of the member s benefits. Please note: BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups. During this transition, you may find that the Group Number listed on a member s identification card is not the same number that appears during an on-line eligibility look up or a HIPAA compliant 270/271 transaction. 27

31 When billling BCBSVT, you can report either number. BCBSVT does not use this information when validating the member s coverage or eligibility for claim processing. New identification cards are issued to members whenever there is a change in: Benefits Membership Primary Care Provider (for managed care members) Below you will find sample cards from each product we offer. The easy-to-find alpha prefix identifies the member s Blue Cross and Blue Shield Plan. The BlueCard suitcase logo may appear anywhere on the front of the ID card. When billling BCBSVT, you can report either number. BCBSVT does not use this information when validating the member s coverage or eligibility for claim processing. New identification cards are issued to members whenever there is a change in: Benefits Membership Primary Care Provider (for managed care members) Below you will find sample cards from each product we offer. The easy-to-find alpha prefix identifies the member s Blue Cross and Blue Shield Plan. The BlueCard suitcase logo may appear anywhere on the front of the ID card. Accountable Blue Subscriber John Subscriber ID: ZIA group Number: BC/BS PLAN: 415/915 Rx group: VT7A Effective Date: mm/dd/yyyy Accountable Blue member 03 Jane Smith Primary Care Physician: J Q Careprovider PREVENTIVE $ 0 PCP $XX SPECIALIST $XX SPECIALIST ACCT BLUE $XX EmERgENCy Room $XX Please refer to your Contract for complete information. Prior approval is necessary for certain procedures and prescription drugs. Visit or call customer service for the list and instructions for requesting prior approval. your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers. For a complete listing, visit customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800) outside of Area: (800) mental Health and Substance Abuse Treatment Prior Approval: (800) Pharmacy: (877) Blue Cross and Blue Shield of Vermont P.o. Box 186 montpelier, VT An Independent licensee of the Blue Cross and Blue Shield Association. Pharmacy benefits manager Blue Card See Section 7 for a sample BlueCard ID card. Indemnity (Fee-for-Service) Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Rx Group: VT7A Effective Date: mm/dd/yyyy Member 03 Jane Smith Comp Plan Refer to your Contract for complete information. Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans. Prior approval is necessary for certain procedures and prescription drugs. Visit or call customer service for the list and instructions for requesting prior approval. customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800) Outside of Area: (800) Inpatient Preadmission/ Admission Review: (800) Mental Health and Substance Abuse Treatment Prior Approval: (800) Pharmacy: (877) Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT An independent licensee of the Blue Cross and Blue Shield Association. Pharmacy benefits manager 28 Comp 301/Comp 102

32 University of Vermont Open Access Plan Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Rx Group: VT7A Effective Date: mm/dd/yyyy Open Access Plan Member 03 Jane Smith Primary Care Physician: J Q Careprovider Office Visit: $20 Refer to your Contract for complete information. Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans. Prior approval is necessary for certain procedures and prescription drugs. Visit or call customer service for the list and instructions for requesting prior approval. uvmcare@bcbsvt.com Customer Service: (888) Provider Service: (888) Outside of Area: (800) Mental Health and Substance Abuse Treatment Prior Approval: (888) Report a hospital admission or surgery: (888) Pharmacy: (877) Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT An Independent licensee of the Blue Cross and Blue Shield Association. Pharmacy benefits manager Vermont Blue 65 (formerly known as Medi-Comp) Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Rx Group: VT7A Effective Date: mm/dd/yyyy Member 03 Jane Smith Vermont Blue 65 Refer to your Contract for complete information. Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans. customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800) Pharmacy: (877) Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT An independent licensee of the Blue Cross and Blue Shield Association. Pharmacy benefits manager Vermont Freedom Plan PPO (VFP) Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Rx Group: VT7A Effective Date: mm/dd/yyyy Vermont Freedom Plan Member 03 Jane Smith OffICE VISIT $20 EMERGENCy $50 Refer to your Contract for complete information. Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans. customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800) Outside of Area: (800) Inpatient Preadmission/ Admission Review: (800) Pharmacy: (877) Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT An independent licensee of the Blue Cross and Blue Shield Association. Pharmacy benefits manager The Vermont Health Plan (TVHP) Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Rx Group: VT7A Effective Date: mm/dd/yyyy The Vermont Health Plan Member 03 Jane Smith Primary Care Physician: J Q Careprovider PREVENTIVE OffICE $0 OffICE VISIT $20 SPECIALIST $30 INPATIENT HOSPITAL $500 OuTPATIENT SuRGERy $200 EMERGENCy ROOM $100 Vermont customerservice@bcbsvt.com Health Customer Partnership Service: (888) Provider Service: (800) Subscriber Please refer to your Contract for Member Outside of 03Area: (800) complete information. John Jane Mental Smith Health and Substance Abuse Treatment Subscriber All services delivered outside The Vermont Primary Prior Approval: Care Physician: (800) ID: Health XYZ Plan s network require Prior J Pharmacy: Q Careprovider (877) Approval. you do not need Prior Approval if your condition meets our definition of an OffICE The Vermont VISIT Health Plan* Group Number: $10 BC/BS Emergency PLAN: Medical 415/915 Condition. SPECIALIST is a controlled affiliate of $20 Effective Date: Providers outside mm/dd/yyyy Vermont should file INPATIENT Blue Cross and HOSPITAL Blue Shield of Vermont* $250 claims with their local Blue Cross and OuTPATIENT P.O. Box 186 SuRGERy $100 Blue Shield Plans. EMERGENCy Montpelier, VT ROOM * Independent licensees of the $50 Blue Cross and Blue Shield Association. Pharmacy benefits manager Vermont Health Partnership (VHP) VHP 201/ VHP 202 Subscriber John Subscriber ID: XYZ Group Number: BC/BS PLAN: 415/915 Effective Date: mm/dd/yyyy Vermont Health Partnership Member 03 Jane Smith Primary Care Physician: J Q Careprovider OffICE VISIT $10 SPECIALIST $20 INPATIENT HOSPITAL $250 OuTPATIENT SuRGERy $100 EMERGENCy ROOM $50 Please refer to your Contract for complete information. Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans. Prior approval is necessary for certain procedures. Visit or call customer service for the list and instructions for requesting prior approval. Page 10 customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800) Outside of Area: (800) Mental Health and Substance Abuse Treatment Prior Approval: (800) Blue Cross and Blue Shield of Vermont P.O. Box 186 Montpelier, VT An Independent licensee of the Blue Cross and Blue Shield Association. VHP 201/ VHP customerservice@bcbsvt.com Customer Service: (800) Provider Service: (800)

33 Member Proof of Insurance Members who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan, addition of member to policy, etc.) are able to print a proof of insurance document from the member website. Below is an example of this document. This document serves as proof of insurance until the identification card is received by the member. It provides the details your practice will need to verify a member s eligibility and benefits on the secure provider website at or by calling the customer service team. Dear, NAME NAME: <Bookmark First and Last Name> DOB: 00/00/0000 MEMBER ID: USID PLAN CODE: 415/915 GROUP: <Bookmark Group Name> GROUP NO: <Bookmark Group Number> PHARMACY: Details provided in table below Certification of Health Plan Coverage If you don t have your ID card, you may use this form as temporary proof of coverage, subject to the terms and conditions of your Certificate of Coverage and your contract documents. 1. Name(s) of any members to whom this certificate applies: Member Name Coverage Start Date Coverage End Date 2. Name and address of plan administrator or insurer responsible for providing this certificate: Blue Cross Blue Shield of Vermont P.O. Box 186 Montpelier, VT Customer Service Team: (800) Pre-Admission Review: (800) PHARMACY DETAILS: Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card. Please note, if you have Medicare Part D coverage, your group may have elected you to have your benefits managed by Blue MedicareRx SM. Please see your separate pharmacy ID card. If Prefix is Pharmacy Group Number is Contact Number DVT, EVT, FVT, FAC, FAH, FAO See pharmacy ID card See pharmacy ID card ZIB VT7A (Express Scripts) - Discount only (877) ZIA, ZID, ZIE, ZIF, ZIH, ZIJ, ZIK, ZIL, ZIU, ZIV, VT7A (Express Scripts) (877) ZIG, ZII L4FA (Express Scripts) (877)

34 If your coverage has ended and you wish to get new coverage, there may be a time limit on when you may do so without being required to wait for an open enrollment period. This period of time can be as little as 30 days from the triggering event causing you to lose coverage. For more information about special enrollment periods and applicable deadlines, please contact: your new employer, if you will get your coverage through work; or Vermont Health Connect, if you will purchase coverage outside of work (855) You can use this form for proof of coverage, if your new coverage requires that you had previous coverage within a certain time period. If you have questions or concerns, you may contact our customer service team toll-free at (800) We re in the office Monday through Friday from 7 a.m. to 6 p.m., except holidays. You may also send us a secure message through our Member Resource Center online by logging into your account at Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits. We look forward to serving you. 31

35 Section 4 Medical Utilization Management (Care Management) The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services. Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program. The focused inpatient utilization is based on an analysis of the individual hospital s utilization and practice patterns, and may vary by provider. Utilization patterns at the network hospitals are reviewed quarterly. As utilization patterns change, the Plan evolves the focus of the inpatient utilization review process. Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter. Integrated health staff also review targeted outpatient procedures and services through the prior approval process. Clinicians are authorized to grant approval for services that meet plan guidelines, and deny services excluded from the benefit plan. A plan physician makes all denial decisions that require an evaluation of medical necessity. Components of the medical utilization management program include: Pre-notification of admissions Prior approval/pre-service Concurrent review Retrospective review/post-service Discharge planning in collaboration with facilities, members and providers Medical claim review BCBSVT provides members, providers and facilities access to a toll-free number for utilization management review. The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 a.m. to 4:30 p.m., Monday through Friday). Integrated health management staff do not place outgoing calls after normal business hours. In addition, members and/or providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non urgent/nonemergent care. Information may also be sent via fax or Web at any time, with the ability to attach clinical information with the request. All inquiries received after hours, will be addressed the next business day. For urgent or emergent care, a clinician and physician are available to providers (by toll free telephone number) 24 hours a day, seven days a week to render utilization review determinations. When speaking with others, the integrated health staff identify themselves by name, title and as an employee of Blue Cross and Blue Shield of Vermont. All inquiries related to specific UM cases are forwarded to integrated health staff for resolution, regardless of where the initial inquiry was received within the Plan. Case managers collect data on all case-managed cases, including the following: Age of member Previous medical history and diagnosis Signs and symptoms of their illness and co-morbidities Diagnostic testing The current plan of care Family support and community resources Psychosocial needs Home care needs if appropriate Post-hospitalization medical support needs, including durable medical equipment, special therapy, and medications/infusion therapy 32

36 The following information sources are considered when clinicians perform utilization management review: Primary care provider and/or attending physician Member and/or family Hospital medical record Milliman Health Care Management Guidelines, Inpatient and Surgical Care and Ambulatory, and Recovery Facility Guidelines Blue Cross and Blue Shield of Vermont medical policies Blue Cross and Blue Shield Association medical policies Board-certified specialist consultants TEC (Technology Evaluation Center) assessment Health care providers involved in the member s care Hospital clinical staff in the utilization and quality assurance departments Plan medical director and physician reviewers A more intensive review occurs for some requested procedure/service(s) based on the need to direct care to specific providers, coverage issues, or based on quality concerns about the medical necessity for the requested procedure/service(s). A more intensive review may require office records and/ or additional medical information to support the request. The services which require additional medical information include, but are not limited to: Possible cosmetic procedures, e.g. breast reduction Organ transplants Out-of-network for point of service product(s) and managed products Experimental procedures/protocols Individual member needs and circumstances are always considered when making UM decisions, and are given the greatest weight if they conflict with utilization management guidelines. In addition, both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria. If the requested services do not meet the Plan s criteria, clinical staff documents the member s clinical needs and circumstances, and any limitations in the delivery system and forward that information to a medical director for a decision. Utilization Review Process The utilization review clinician may contact the facility utilization review staff and/or the attending provider to obtain the clinical information needed to approve services. However, if the utilization review clinician cannot obtain sufficient information to determine the medical necessity, appropriateness, efficacy, or efficiency of the service requested, and/or the review is unresolved for any other reason, the Plan s clinical reviewer refers the case to a Plan provider reviewer. The Plan s provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case. In making the final determination, the actual clinical needs take precedence over published review criteria. In the event of an adverse decision, both the member and participating provider can request an appeal. The appeal procedure is documented more specifically later in this document. During the concurrent review process, if services or treatments are provided to the member that were not included in the original request, and are determined to be not medically necessary, the Plan may deny those services or treatments and the member is not to be held liable. This means that the member is not penalized for care delivered prior to notification of an adverse determination. For further details see provider contracts. BCBSVT utilization staff will not accept any financial incentive relating to UM decisions. 33

37 Clinical Practice Guidelines The BCBSVT Quality Improvement Policy, Clinical Practice Guidelines provides the details on the policy, policy application and annual review criteria. The policy is located on the secure provider portal at under BCBSVT Policies, then the Quality Improvement link. Or, you can call your provider consultant for a paper copy. Clinical Review Criteria The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence, and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment, or diagnose or manage the medical condition. Such guidelines include nationally recognized health care guidelines, MCG, Level of Care utilization System (LOCUS), Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria. In addition to the national guidelines mentioned above, the Plan s internal medical policy and the Blue Cross and Blue Shield Association Medical Policy and/or the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy, benefit coverage and utilization management. The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which, along with other information, a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to: Administer national accounts as they may decide to have their employee benefit coverage so interpreted. Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy, utilization management, managed care and quality assessment programs. These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice, taking into account input from practicing physicians, psychiatrists, and other health providers, including providers under contract with the Plan, if applicable, and are available to all providers under contract with the Plan, as well as to members and their treating providers upon request. Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) , phone (800) , option 1, or mail at BCBSVT, PO Box 186, Montpelier, VT The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Substance Use Disorders Clinical Practice Guidelines Evaluation and Management of Congestive Heart Failure in the Adult, American College of Cardiology and American Heart Association: Global Initiative for Chronic Obstructive Lung Disease a Pocket Guide to COPD Diagnosis, Management and Prevention, a Guide for Health Care Professionals: Treating Patients with Substance Use Disorders, Alcohol, Cocaine and Opioids, American Psychiatric Association: Treating Major Depression, American Psychiatric Association: 34

38 The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations, Adult and Children and Adolescent Clinical Preventive Services, and treatment of Substance Abuse, Opioid Abuse, and Depressive Disorder. Nationally recognized experts developed these guidelines. The guidelines are available for you to read or print on the following websites: Adult Preventive Immunization, Centers for Disease Control and Prevention: Pediatric Preventive Immunizations, Centers for Disease Control and Prevention: USPSTF Recommended Adult Preventive Guidelines, U.S. Preventive Services Task Force: USPSTF Recommended Preventive Guidelines for Children and Adolescents, U.S. Preventive Services Task Force: Guidelines for the Treatment of Patients with Substance Abuse, Opioid Abuse, American Psychiatric Association: aspx Guidelines for Treatment of Patients with Depressive Disorder, American Psychiatric Association: In addition to the nationally recognized preventive health and clinical practice guidelines listed above, BCBSVT bi-annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted. The Plan has adopted guidelines for the treatment of Chronic Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Asthma, Overweight and Obesity, and Hypertension. The guidelines may be evidence-based guidelines or consensus guidelines developed by providers. These guidelines are available at by calling Customer Service at (800) or by ing Advanced Benefit Determination Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determination. This allows members and providers to submit a written request asking about benefit availability for specific services, and receive a written response. You can use the prior approval form for submission of FEP advanced benefit determinations, but you will need to clearly mark the form (preferably at the top) Advanced Benefit Determinations. If the prior approval form is not clearly marked, it will be assumed you are submitting for prior approval only. A complete list of services requiring prior approval for FEP members is available on our provider website at under the Prior Approval/Pre-Notification/Pre-Service request link. Prior Approval/Referral Authorization (referral authorizations are only required for members with the New England Health Plan) Prior approval/referral authorization is required for coverage of selected supplies, procedures, and pharmaceuticals before services are rendered, as outlined in member certificates and outlines of coverage. Even members with BCBSVT/TVHP as a secondary carrier, including those with Medicare as the primary carrier, need to obtain a prior approval for applicable services. These lists are updated annually based upon Vermont practice patterns. The current lists are available on the provider resource center located at Requests for prior approval/referral authorization can be submitted by phone, mail, fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures, or pharmaceuticals. These prior approval/referral authorization requests may come from the referring provider, the servicing provider or the member. Forms can be obtained from the provider resource center located at or by calling customer service. Note: Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont. If the member has selected a PCP in any other state, the local Blue Cross and Blue Shield Plan s prior approval/referral authorization guidelines will apply and requests need to be submitted directly to that Plan. Prior approval/referral authorization requests are reviewed by a Plan clinician, a Plan/TVHP medical director, a Plan contract dentist reviewer, a Plan pharmacist reviewer, or a Care Advantage Inc. (CAI) consultant medical director. The clinician may approve services but does not issue medical necessity denials. The dentist and pharmacist reviewers only review requests pertinent to their disciplines. Determinations to deny or limit services are only made by physicians under the direction of the medical director. Upon receipt, the reviewer evaluates the prior approval request. If insufficient information is present for determination, additional information is requested, in writing, from the member or provider. The notice of extension specifically describes the required information. The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified 35

39 information. If no additional information is received, the Plan will deny the request for benefits as not medically necessary based on the information previously received, and the charges may be denied when claims are submitted without prior approval. Once the information is sufficient for determination, the registered clinical reviewer approves requests that meet pre-established medical necessity criteria and are covered benefits. If medical necessity criteria are not met, the registered clinical reviewer refers the case to a Plan medical director for decision. The physician reviewer may request additional information or contact the requesting physician directly to discuss the case. Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features. References used to make determination include, but are not limited to the following: Blue Cross and Blue Shield Association TEC Assessment Blue Cross and Blue Shield Association Medical Policy Manual Blue Cross and Blue Shield of Vermont Medical Policy Manual Medical director review of current scientific literature Review of specific professional medical and scientific organizations, (i.e. SAGES) Milliman Care Guidelines, Current Edition Once a determination is made, the member, provider and the referred-to-provider are notified in writing for approvals and denials. Decision letters contain the following: A statement of the reviewers understanding of the request; If applicable, a description of any additional material or information necessary for the member to perfect the request and an explanation of why such material or information is necessary; If the review resulted in authorization, a clear and complete description of the service(s) that were authorized and all applicable limits or conditions; If the review resulted in adverse benefit determination, in whole or in part The specific reason for the adverse benefit determination, in easily understandable language The text of the specific health benefit plan provisions on which the determination is based; If the adverse benefit determination is based on medical necessity, an experimental/investigational exclusion, is otherwise an appealable decision or is otherwise a medically-based determination: an explanation of the scientific or clinical judgment for the determination, and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the member s circumstances; If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline protocol, or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule, guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or, in the case of concurrent or urgent pre-service review, immediately upon request; If the review is concurrent or pre-service, what, if any, alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested; A description of grievance procedures and the time limits applicable to such procedures; In the case of a concurrent review determination or an urgent, pre service request, a description of the expedited grievance review process that may be applicable to such requests; A description of the requirements and timeframes for filing grievances and/or a request for independent external review in order for the member or provider to be held harmless pending the outcome, where applicable; Notice of the right to request independent external review after a grievance determination, in the language, format and manner prescribed by the Department; and Local and toll free numbers for the department s health care consumer assistance section and the Vermont Office of Health Care Ombudsman. For all lines of business, the Plan adheres to Vermont Rule H , NCQA accreditation, and federal timeliness standards. For non urgent pre-service review decisions, the Plan must provide written notice of adverse determination to the member and treating provider (if known), within a reasonable period, not longer than two business days after receipt of the request. Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification. 36

40 If additional information is needed because of lack of information submitted with the prior approval request, the Plan sends a written request for additional information within two business days of receipt of the request. The notice of extension specifically describes the required information. The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information. The Plan does not retroactively deny reimbursement for services that received prior approval, except in cases of fraud including material misrepresentation. See provider contracts for more complete details. Note: Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy Part B are reviewed by CBA Blue. See Dental Care in Section 6 for more details. Pharmacy prior approvals are reviewed by Express Scripts, Inc. (ESI). Note, however, not all members have pharmacy coverage through BCBSVT. Refer to our Contact Information for Provider sheet on our provider website under Pharmacy Benefit Manager for a list of exclusions. Radiology prior approvals are reviewed by AIM Speciality Health. Special Notes Related to Prior Approval for Ambulance Services Refer to the current prior approval listing to determine which ambulance service(s) require prior approval. We encourage the referring provider to obtain prior approval for ambulance services. Ambulance providers cannot contract with BCBSVT and therefore, members are financially responsible for the services provided if prior approval is not obtained. In addition, the referring provider has the clinical information we need to make a decision. When a rendering provider is requesting a prior approval for ambulance services, they need to know the ambulance service name, location and national provider identifier. No coding is necessary. BCBSVT uses an ambulance transport service code. BCBSVT has two business days to review and make decisions on ambulance prior approval requests, unless they are marked urgent. Urgent requests have 48 hours to have a decision rendered. If you have enough time to file for prior approval before the transport, you should not mark the request as urgent. Special Notes Related to Prior Approval/Referral Authorization: Home Health Agencies or Visiting Nurse Associations: a new authorization or an update/extension of an existing authorization does not need to be submitted or created should a member experience an inpatient admission during date spans for already approved services. If the inpatient stay results in the need to adjust the date span of already approved services, or will result in services spanning a new calendar year, you need to contact our integrated health team at (800) We will adjust the existing authorization accordingly. Retrospective review of prior approvals, and referral authorizations Prior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered. Providers and facilities are held financially responsible. However, we will conduct a retrospective review for medical necessity, when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required. Provider must contact BCBSVT within a reasonable time, not to exceed 60 calendar days from the date of service, unless documentation provided, Chiropractic Services Chiropractic services rendered within three (3) days of visit following visits 12th, 18th, 24th, etc. visits Coverage Unknown, Changed or Incorrect Provider not aware member had BCBSVT coverage Provider not aware member had a change in BCBSVT coverage Provider advised member was not active through eligibility verification Provider received incorrect information about member s coverage (eligibility, benefits or Medicare status) 37

41 Discharge Planning Discharge planning occurred during the Plan s non-business operating hours Durable Medical Equipment (DME) Continuation Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAP/BiPAP/TENS or any other continued DME Genetic Testing Request received within 60 days of the specimen being collected and sent to the lab for processing Misquote BCBSVT/AIM or ESI quoted that a service, procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list Treatment Plan Change Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedure/service Provider determines additional services that require prior approval are needed during a procedure/surgery Provider has an approved prior approval on file, but determines the need for other or additional services during a procedure or a change in treatment plan is required Provider received approval for a specific code(s), but when the procedure was rendered the code(s) changed by the National Coding Standards Unable to reach BCBSVT and/or delegated vendor partners Provider attempted to obtain prior approval, but was unable to reach BCBSVT due to extenuating circumstances (natural disaster, power outage) Requesting a Retrospective Review If a provider identifies a service that qualifies for a retrospective review, he/she must submit a prior approval form noting it is a retrospective review and includes documentation that: 1. Supports the procedure provided and 2. Provides details of why prior approval was not originally requested. We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review. Retrospective Reviews of Prior Approval Misquotes If Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing), Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote. Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization. BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Provider s receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization. Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote, and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVT s website. Pre-notification of Admissions Under the Plan s certificates of coverage, pre-notification of scheduled inpatient admission is required. Pre-notification enables the Plan s Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient). Clinical information pertinent to the request is collected as needed. The information is reviewed in conjunction with nationally recognized health care guidelines and/or other data sources identified earlier in the description. 38

42 If the Integrated Health staff cannot certify the request, the case is referred to a Plan medical director. The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination. The medical director may approve or deny a service. Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request. Copies of the letter are sent to the treating providers, facility and member. The Plan s integrated health department also keeps a copy as part of the member s electronic record. In the case of an adverse determination, the appeal process is outlined in the letter and is also discussed later in this program description. Each case reviewed is evaluated for case and/or disease management. Both integrated health staff and physician reviewers participate in a team effort that focuses on the member s unique needs. The appropriateness of services, access to, cost effectiveness and quality of services are all stressed. The Plan does not retroactively deny reimbursement for services that received prior approval/pre-notification except in cases of fraud, including material misrepresentation. See provider contracts for more complete details. Admission Review All admissions that require review, but occur without pre-notification, are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan. Admission reviews in this category are reviewed as noted above. A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day, seven days a week, to render utilization review determinations for urgent or emergent care. Verbal notifications of all urgent and non-urgent decisions are made within 24 hours to both the member and provider. Written notifications are issued within 24 hours of verbal notification. Concurrent Review Concurrent review applies to inpatient hospitalization or any ongoing course of treatment. During inpatient hospitalization for circumstances requiring focused review, the Plan s clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines, Current Edition and/ or locally approved health care guidelines. Through telephonic review, the Plan s clinician reviews the medical information provided by the facility s UR staff while the member is hospitalized. Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the member s unique needs. The Plan uses the concurrent review process to facilitate discharge planning with the treatment team. If there is a length of stay or level of care issue, it is discussed with the Plan s medical director and if necessary, the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information. In the event of an adverse decision, verbal notification is provided to the member and treating provider (if known), and a written notification is sent, within 24 hours of the verbal notification, to the member and the provider(s). During the concurrent review process, if the integrated health staff identifies a quality of care issue, the case is referred to the QI department or the credentialing committee for investigation. The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy, Quality of Care and Risk Investigations Policy to complete the investigation. The policy is located on the secure provider portal at under BCBSVT Policies, then the Quality Improvement link. Or, you can call your provider relations consultant for a paper copy. The Plan does not retroactively deny reimbursement for services that received prior approval/pre-notification except in cases of fraud, including material misrepresentation. See provider contracts for more complete details. Discharge Planning and Discharge Outreach Discharge planning occurs during the inpatient concurrent review process. During the concurrent review process, the Plan s clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services. The extent of the clinician s direct role in planning and arranging post-discharge care varies with the patient needs and includes a collaborative approach with the hospital staff, care team, patient/family and community resources representatives as appropriate. Upon discharge, each member is contacted by the discharge outreach coordinator, a clinician who reviews the member s discharge plan and assists with coordination of services as needed. During the outreach, the clinician will assess the need for referral to case management, disease management or behavioral health management and will facilitate said referral if applicable. 39

43 Urgent Pre-Service Review Urgent pre-service review applies to any request in which the member s health could be compromised by delay. Expedited decisions are reached and providers are notified within 72 hours of the request. Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification. Case Management Blue Cross and Blue Shield of Vermont adopted the Case Management Society of America s case management definition: Standards of Practice for Case Management, revised Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual s health needs through communication and available resources to promote quality, cost-effective outcomes. The specialty case management program is a member-centered, proactive program designed to identify at-risk members as early as possible. The program works collaboratively with our disease management, behavioral health, dental, and pharmacy partners, and is focused on chronic diseases that are typically high-cost and are potentially actionable with appropriate intervention and lifestyle changes. The clinical case manager applies the four primary functions of case management: advocacy, assessment, planning and facilitation, to identify barriers to the member attaining appropriate, timely and quality care. The program is an organized effort to identify potentially high cost/high risk members with complex health needs as early as possible, assess alternative treatment options, assist in stabilizing or improving member s health care outcomes and manage health care benefits in the most cost effective manner. The managed diagnostic categories and focus populations include diabetes, general, HIV/AIDS, acute and chronic neurology, progressive degenerative disorders, end of life/palliative care, high-risk obstetrics, pediatrics, transplant and oncology with or without metastasis. The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and if necessary, updates the case management process and case management resources to address member needs. If it is determined that the member has the potential to benefit from case management, a welcome packet is sent defining case management s role and the member s rights and responsibilities in participation. Once the member consents to participate in and collaborate with the case manager, a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team. In collaboration with the member, case manager and provider, a member-specific case management plan of care is developed to support the member s clinical plan of care, which includes both short and long term, prioritized goals, nursing interventions, a member self-management plan and discharge criteria. Case management services may be terminated once the goals are met and the member no longer requires case management services or, since the program is voluntary, the member requests termination of services. Case management services can be reinstated at any time. All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney. Episodic Case Management/Authorization of Services Episodic case management/authorization of services targets individuals who have short-term intervention needs, usually for a period of six to 12 weeks or for a specific illness episode. This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized. The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum. Provider Referrals to Case or Disease Management Providers are encouraged to refer BCBSVT/TVHP members directly into our case or disease management programs by calling (800) , option 3. Our intake triage staff will record the information and complete outreach to the member for enrollment. Rare Condition Program (BCBSVT partnership with Accordant Health Services) The BCBSVT Rare Condition Program can help your patients improve their conditions, enhance their knowledge and self-management skills and achieve your therapeutic goals for them. Full details are available in our online brochure located on the provider website under Provider Manual/Reference Guides/General/Accordant. 40

44 Section 5 Quality Improvement (QI) Program Blue Cross and Blue Shield of Vermont and The Vermont Health Plan s Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members. Both organizations are referred to here as the Plan. To receive a copy of the Plan s Quality Improvement Program Description, contact the Director of Quality Improvement at (802) The Plan QI program identifies the leading health issues for our members, areas where current treatment practice runs counter to established clinical guidelines and, by working with both members and providers, takes action to modify or improve current treatment practice. In addition, the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers, takes action to improve service. Input from both providers and members is essential to meeting the goals of our program. Some of the Plan s quality improvement initiatives that affect providers are outlined below. The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation. Quality Improvement Projects: As part of their participation in managed care products, the Plan expects its provider network to contribute to the success of the Plan s quality improvement projects. The projects define a measurable goal around a specific clinical issue in a particular population, identify barriers that contribute to gaps in care, implement member and provider interventions to address the issue, measure the success of the project and then reassess barriers and interventions. Through FinePoints, a newsletter to the provider community, and other notifications, the Plan alerts its provider network to its quality improvement projects and the role of providers. The Plan expects providers to participate in the quality improvement project, encourages members to participate and provides feedback on the project. Quality Profiles: Each year, the Plan compares practice patterns in Vermont to nationally recognized guidelines. The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers. In cases where practice patterns seem inconsistent with national guidelines and the Plan s standards, the Plan takes appropriate action to correct deficiencies, monitors provider performance against corrective actions, and takes appropriate and significant action when a provider does not follow through on corrective action. Clinical Guidelines: The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals. The Plan reviews and, as appropriate, updates its clinical guidelines a minimum of every two years, and distributes the guidelines to providers within the relevant practice area. Medical Record Reviews & Treatment Record Reviews: The BCBSVT Quality Improvement Policy, Medical Record Review & Treatment Record Review provides the complete details of the definitions, review procedure performance improvement plans, and reporting. The policy is located on the secure provider portal at under BCBSVT Policies then the Quality Improvement link. Or, you can call your provider consultant for a paper copy. Member Satisfaction Surveys: The Plan surveys members who have sought services from primary care or OB-GYN physicians to assess their satisfaction with these network physicians. Periodically, the Plan shares results of member satisfaction surveys with physicians. In cases where member satisfaction is not consistent with the Plan s standards, the Plan takes appropriate action to correct deficiencies, monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action. Member Complaints: The Plan documents and tracks member complaints and may, as appropriate, share results with network providers. In circumstances where member complaints focus attention on a specific concern about a provider, the Plan may share the feedback with the provider, engage the provider in developing corrective action, monitor the provider s performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action. HEDIS and Quality Data Gathering: On an annual basis, the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and, at the same time, gathers data to support its quality improvement projects. HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators. The Plan s 41

45 participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members. Standards of Care: Each year, the Plan develops or adopts standards of care relevant to the health needs of the Plan s membership. The Plan distributes guidelines to its networks and measures guideline compliance. The Plan updates the guidelines at least every two years. The Plan has adopted clinical practice guidelines in the following areas: asthma, hypertension, diabetes, smoking cessation, obesity, obstructive sleep apnea, depression, preventive health, adult migraine headaches, anti-depressant medication follow-up, colonoscopy and acute pharyngitis. Provider Feedback: Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program. There are many ways that providers can let us know how we re doing: 42 Contact a provider relations representative at (888) Provider complaints call our Customer Service department at (800) The Plan logs and reports on complaints regularly to note trends and areas of particular concern. Provider Satisfaction Surveys conducted annually and mailed to every provider in our network. Look for yours every fall. Participation in quality improvement committees is outlined below. Quality Improvement Committees The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Plan s quality improvement program. The Plan invites providers to contact the quality improvement department at (802) if they would like to participate in a quality committee. Quality Oversight Committee: This committee provides oversight of the quality improvement program. It reviews HEDIS and CAHPS data and other quality indicators, identifies and prioritizes quality improvement opportunities, develops and oversees quality improvement projects and other quality activities and serves as liaison for the Plan s quality program and the provider network. The committee meets six times a year. Quality Improvement Project Teams: Through quality improvement projects, the Plan seeks to improve the care and service its members receive, both from the Plan and its networks. The projects are carried out through the work of a team made up of clinical and non-clinical staff. The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects. Credentialing Committee: The Plan s credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan. In addition, the Plan s credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations. Specialty Advisory Committee (SAC): The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont. Examples of past SAC topics include cardiology, orthopedics, oncology and OB-GYN. The Plan encourages network providers to propose SAC topics or to volunteer for a SAC. BCBSVT/TVHP Special Health Programs Better Beginnings Better Beginnings is a voluntary and comprehensive prenatal program. The program identifies early in their pregnancies those women who may be at risk for pregnancy complications. It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs. Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre-term labor and/or other complications. All BCBSVT members are eligible for the program, with the exception of the Federal Employee and New England Health Plan programs. An expectant mother can enroll at any time during her pregnancy, but BCBSVT must receive enrollment paperwork prior to delivery. Ideally, a member will enroll as early as possible in her pregnancy. There is a reduction in benefits if a member enrolls after 34 weeks gestation. Please refer the expectant mother to the website: on information on how to register.

46 Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed. We send educational materials on pregnancy and childbirth to the expectant mother. The same RN case manager will follow the member through her pregnancy and in the postpartum period. The nurse may offer case management if the expectant mother is at high risk for complications. If you would like more information on the Better Beginnings Program, or would like to refer a patient, please call (800) , select option 1. Members may also call our Customer Service department at (800) for more information about the Better Beginnings Program. Brochures for this program are available free of charge. These brochures can be placed in your waiting areas, or you may include them in patient care kits. To order a supply, simply contact your provider relations representative at (888) and request Better Beginnings Program brochures. Diabetes Education/Training BCBSVT/TVHP provides a benefit for outpatient diabetes self-management education/training services and related durable medical equipment and supplies for eligible members. This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease. Providers of outpatient diabetes educational/training services must participate with the Plan and meet the Plan s credentialing criteria for diabetes education in order to be eligible for reimbursement. Eligible providers must submit a separate credentialing application, specific to diabetes education, to BCBSVT/TVHP. The credentialing procedures are similar to those outlined in section one, but the Plan also requests information on providers certification and training in the education and management of diabetes. Benefits are available for diabetes self-management eduction/training services for eligible members if all of the following criteria is met: The member has one of the following diagnosis: Insulin dependent diabetes Gestational diabetes Non-insulin dependent diabetes The member is capable of self-management, including self-administration of insulin (or in the case of children, parental management) A qualified outpatient diabetes education/training education program that participates with the Plan. Hospice The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement. The attending physician, in collaboration with a participating home health agency, prepares a comprehensive home care treatment plan in order to assure the member s comfort and relief from pain. Benefits: We cover the following services, by a Hospice Provider and included in the bill: skilled nursing visits; home health aide services for personal care services; homemaker services for house cleaning, cooking, etc; continuous care in the home; respite care services; social work visits before the patient s death bereavement visits and counseling for family members up to one year following the patient s death; and other Medically Necessary services. Requirements: We provide benefits only if: the patient and the Provider consent to the Hospice care plan, and a primary caregiver (family member or friend) will be in the home. 43

47 BlueHealth Solutions The Blue HealthSolutions information and support program helps our members learn about the care they re getting. The various components of the program (a 24-hour phone-in nursing support line, an advertising-free website and a self-help book among them) help our members to learn about all the options available. If a member has a chronic or serious condition, they can get phone support, information by mail and videotapes on a range of diagnoses and treatment options from our clinicians. If a member needs answers to everyday problems, our clinicians provide easy access at any time of the day or night by phone or via the web. Members can call toll-free (866) to speak with one of our clinicians. In addition to health management and support programs, BCBSVT has a host of fun, effective programs designed to reward our members for healthy behavior. Among them: WalkingWorks, a program that makes it easy and fun to keep track of the success at walking for fitness BlueExtras, a program that provides discounts on weight loss programs, hearing aids and a host of local goods and services EatSmart Vermont, a program that encourages restaurants to offer and promote healthy choices on their menus At BCBSVT, our goal is to ensure that all our members get the care and support they need, regardless of their health care status. Our full spectrum of Blue HealthSolutions programs allows us to maximize each member s chance at getting and staying healthier. By using Blue HealthSolutions, our members make the best use of the dollars they spend on health benefits. Provider Selection Standards To participate in the BCBSVT or TVHP s networks, a provider must 1. Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers, including but not limited to professional nurse midwives, massage therapists, and acupuncturists) 2. Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant 3. Agree to a recredentialing review every three years as outlined in the Recredentialing Policies 4. Provide a complete application including an attestation of Ability to perform the essential functions of the position Lack of illegal drug use at present History of loss of license and/or felony convictions History of loss or limitation of privileges or disciplinary action Accuracy and completeness of information 5. Agree to the Plan s access and appointment availability standards as specified in Vermont Rule Agree to provide 24-hour coverage (primary care providers only) 7. Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services) 8. Agree to BCBSVT and/or TVHP payment rates 9. Agree to sign a contract with BCBSVT and/or TVHP and adhere to the contractual provisions. Provider Appeal Rights The Plan may deny a provider s participation in its networks for reasons related to credentialing criteria, quality or performance. Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial. A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Investigation and Resolution of Quality of Care Issues and Appeals, available upon request from your provider relations representative. 44

48 Credentialing verification is required for all lines of business to review the background and performance of physicians/providers and to determine their eligibility to participate in the network. Credentials such as current license, license history, specialty, Drug Enforcement Agency (DEA) Certificate, malpractice history and education are verified when a provider enters into the network and again every three years. Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs). The Plan monitors these delegates credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR). Recredentialing Procedures The Plan recredentials all network providers and facilities every three years. Providers and facilities must return a completed recredentialing application. The Plan will conduct primary source verification and a performance appraisal for the credentialing committee s review. Performance appraisal elements include Member complaints Member satisfaction surveys Quality Improvement profiles Quality reviews (site visits and medical record reviews) Utilization management review Confidentiality Credentialing information obtained in the credentialing process is kept in a locked/secured area. All Plan employees sign a confidentiality statement as a condition of employment. All materials and processes are subject to the standards outlined in the Plan s Confidentiality and Security Policy, available upon request. All credentialing information shall be retained for a minimum of two credentialing cycles or for six years, whichever is longer. The minutes and records of the credentialing committee are confidential and privileged under 26 V.S.A. 1443, except as otherwise provided in 18 V.S.A. 1914(f)(2) and Vermont Rule (B). Providers may request a copy of the Plan s Credentialing Policy from our Provider Relations Department by calling (888) Medical and Treatment Record Standards Medical Record Review The Plan requires all providers to maintain member records in a manner that is current, detailed and organized, permitting effective member care and quality review. Records may be written or electronic. The Plan conducts a medical record review of its high-volume primary care providers and a treatment record review of its high-volume mental health and substance abuse providers at least every three years, we check for critical elements, general elements and confidentiality, and organized record keeping policies. The Plan does not include Blueprint practices using electronic records, as the state deems them compliant with this requirement. To pass the review, provider records must reflect 100 percent compliance with critical elements, confidentiality, organized record keeping policies, and 80 percent compliance with the general elements. The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards. The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review, and conducts a repeat review in approximately six months time. The Plan will maintain all results and correspondence relating to record review, in the secure credentialing database. The Plan may use these results to make future credentialing decisions. The complete Medical Record Review & Treatment Record Review policy is available on our secure website. We would encourage you to review for the full details. If you encounter any issues or are unable to access the web, please contact your provider relations consultant at (888)

49 Retrieval and Retention of Member Medical Records Members must have access to their medical records during business hours, for a charge not to exceed copying costs. The Plan will have access to member medical records during regular business hours to conduct quality improvement activities. Providers retain records as per individual practice policies in accordance with all state and federal laws. Office Site Review The BCBSVT Quality Improvement Policy, Site Visit and Medical Record Keeping Policy provides the complete details of the requirements. The policy is located on the secure provider portal at under BCBSVT Policies, Quality Improvement. Or, you can call your provider relations consultant for a paper copy. 46

50 Section 6 General Claim Information Our mission is to process claims promptly and accurately. We generally issue reimbursements on claims within 30 calendar days. Industry Standard Codes Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form. Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and / or Health Care Procedure Coding Systems (HCPCS). To align with the industry, on a quarterly basis (January, April, July and October) BCBSVT also updates the CPT and HCPCS codes. We complete a review of the new/revised/deleted codes and post a notice to the news area of our provider website at advising of any changes in prior approval requirements, changes in unit designation, and any other information you should be aware of specific to the new/revised/deleted codes. The posting appears no later than two weeks prior to the effective date. Diagnosis must be reported using Internal Classification of Disease, 10th revision, Clinical Modification (ICD-10-CM). ICD-10 diagnosis codes are to be used and reported at their highest number of characters available. The Plan begins to use the newest release of ICD-10-CM in October of each year. Balance Billing Reminders Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services. Providers will not bill members, except for applicable co-payments, coinsurance or deductibles. Non-Covered Services In certain circumstances, a provider may bill the member for non-covered services. Please refer to Section 1 Billing of Members and Non-Covered Services for details. Reimbursement Payments for BCBSVT and TVHP are limited to the amount specified in the provider s contract with BCBSVT and/or TVHP, less any co-payments, coinsurance or deductibles in accordance with the member s benefit program. Claim Filing Limits New Claims New Claims must be submitted no more than one hundred eighty (180) days from the date of service, or in the case of a coordination of benefit situation, one hundred eighty (180) days from the date of the primary carrier s payment. Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member. A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial. The Provider Inquiry Form must include supporting documentation such as original claim number, copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit, or a copy of the computerized printout of the patient account ledger with the submission date circled. Requests for review of untimely filing denials will be reviewed on a case-by-case basis. If the denial is upheld, a letter will be generated advising the provider of the outcome. If the denial is reversed, the claim will be processed for consideration on a future Remittance Advice. Adjustments Must be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial. Claim submission when contracting with more than one Blue Plan: Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT. We have created three guides to assist these providers, the guides are located on our provider website at Grace Period for Individuals through the Exchange Individual members enrolled through the State s Health Exchange have very specific grace periods. 47

51 The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three-month grace period for non-payment of premium before their membership is terminated. BCBSVT administers the grace period as follows: Claims for dates of service during the first month of grace period: We process the claims, make applicable payments and reports through to a remittance advice. These payments are never recovered even if the membership terminates at the end of the grace period. If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims, simply submit following our standard guidelines, and the adjustment will process through as usual. If additional money is due, it will be paid. Claims for dates of service during the second and third month of the grace period: Claims are suspended. We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address. If the premium is paid in full at any point during month two or three, the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts. If the premium is not paid in full prior to the end of the three-month grace period, the suspended claim(s) is denied through to a remittance advice and reports as membership not on file reflecting the full billed amount as the member s liability. The member also receives an explanation of benefits with this information. Per the Affordable Care Act, when a member is within a grace period, they must pay all amounts due, up through their current billing period to keep their insurance active. Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed. They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice. If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete. Take Back of Claim Payments & Overpayment Adjustment Procedures It is BCBSVT s and TVHP s policy to collect any overpayments made to the provider in error. When membership is terminated retroactively, BCBSVT and TVHP recover payments made for services provided after the termination date. Providers should then bill the member directly. Individuals who are covered through the Exchange have separate guidelines. For full details see Grace Period for Individuals Through the Exchange. If we learn of other insurance or other party liability, BCBSVT and TVHP recover payments made for services. BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims. Cotiviti Healthcare looks at the following COB concepts: Active/Inactive Automatic Newborn Coverage Birthday Rule Dependent/Non dependent Divorce Decree Longer/Shorter Medicare Age: Entitlement, Disability Entitlement, Crossover, Domestic Partner, ESRD Entitlement, Home Health, Part B only Cotiviti also performs claim reviews for (1) duplicate services, (2) claims suspected to have administrative billing and payment errors, (3) BCBSVT observation services payment policy, and (4) BCBSVT provider based billing payment policy. 48

52 Most of the reviews are performed without requiring any additional information from providers. They rely on the information contained on the claim(s), attachment(s) or information BCBSVT has already collected during the initial COB process. Cotiviti Healthcare may need to outreach to your office directly to obtain more information. Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare. You can release the requested information to them directly. Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request. Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing for: Facility billing (including DRG reimbursements) High cost injectable drugs Home infusion Renal dialysis If you receive a request for information from Change Healthcare (or EquiClaim, as they still use that name at times) please make sure to respond promptly. When you detect an overpayment, please do not refund the overpayments to BCBSVT/TVHP or the patient. Instead, please complete a Provider Overpayment form. For an accurate adjustment, it is important to include all the information requested on the form. We will adjust the incorrectly processed claim by deducting from future payments. We prefer to recover, rather than accept funds from you, because: Claims history will simultaneously be corrected to accurately reflect the service and payment, The remittance advice will reflect correction of the original claim, and Providers do not incur the expense of sending a check. The Provider Overpayment form is available on the provider website. Accounting for Negative Balances When the Plan needs to correct an overpayment on a claim, the amount of the incorrect payment is automatically deducted from future payments to the provider. The overpayment adjustment will report as a negative on the provider s Remittance Advice. The amount due will be subtracted from the total payment for the Remit. When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice, a negative balance is created. The negative balance will report through to every Remit until the balance is cleared up. Do not issue checks to the Plan for the amount the report shows as a negative. Typically, negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment. Please note: Negative balances do not cross product lines. For example, if you have a negative balance on a BlueCard remittance advice, the outstanding negative balance would not be taken on your indemnity, TVHP or FEP remits. It would continue to be taken on your next BlueCard remittance advice. Where to Find Co-payment Information A co-payment is an amount that must be paid by the member for certain covered services. This amount is charged when services are rendered. The amount of co-payment can be obtained by: Checking the front of the member s identification card, Using the secure website at (see Section Two of this manual for details), or PCPs can refer to the monthly membership reports. Co-payments and Health Care Debit Cards Some members, to cover out-of-pocket costs, use healthcare debit cards. Out-of-pocket expenses are co-payments, deductibles and/or coinsurance amounts that are not paid by the member s health plan. Debit cards typically have a major debit card logo such as MasterCard or Visa. 49

53 Some BlueCard members have a Blue Cross and/or Blue Shield health care debit card a card with the nationally recognized Blue Cross and/or Blue Shield logos, along with the logo from a major debit card. The debit card should only be used to collect co-payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim). If a member arrives for an appointment and presents a debit card, you may charge the co-payment amount to the debit card. Please be sure to verify the co-payment amount before processing payment. The card should not be used to process the full charges up front. Submit the member s claim to BCBSVT. Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member. The member may choose to pay any balances due with the debit card. In that case, the member would bring the card to your office and authorize the payment. How to Use a Health Care Debit Card The cards include a magnetic strip, so if your office currently accepts credit card payments, you can swipe the card at the point of service to collect the member s payment. Select credit when running the card through for payment. No PIN is required. The funds will be sent to you, and will be deducted automatically from the member s appropriate HRA, HSA or FSA account. Waiver of Co-payment or Deductible There may be situations where a provider does not want to collect a co-payment (or deductible) from a member, or where the provider wishes to collect a lesser amount than that which is due under the terms of a member s benefit program. The circumstances under which a provider may waive all or a portion of a co-payment or deductible due from a member are limited, however. A provider may not waive a member s co-payment or deductible in an attempt to advertise or attract a member to that provider s practice. A provider should limit waiver of co-payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding-scale) and (2) the member in question meets the criteria for reduced or waived payment. When to Collect a Co payment High Dollar Imaging When a member has a co-payment for high dollar imaging, the co-payment amount is only taken on the facility claim. The professional (reading) claim will not apply a co-payment. For plans with a co-payment and then a deductible, the facility claim will take the co-payment and any applicable deductible. The professional (reading) claim will take only the applicable deductible. Please note: Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging. Mental Health and Substance Abuse BCBSVT members have access to certain mental health and substance abuse services for the same co-payment as their primary care provider visit. A list of these services are available on our provider website at under policies, provider manual & reference guides, mental health and substance abuse co-payment. 50

54 Physician s Office A co-payment is collected when an office visit service is rendered. Generally, co-payments are applied to the Evaluation and Management (E & M) services, which include office visits and exams performed in the physician s office. BCBSVT and TVHP s reimbursement excludes the co payment that the physician collects from the member. If a member has two BCBSVT policies, the member is responsible for one co-payment; the policy with the lowest co-payment for the service will apply the co-payment. For example, if the primary BCBSVT policy has an office visit co-payment for $20 and the secondary BCBSVT policy has an office visit co-payment of $10, the member will only be responsible for a $10 co-payment. Preventive Care: BCBSVT/TVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their grandfathered employer benefit and do not take a co-payment. Grandfathered preventive care follows the traditional BCBSVT preventive guidelines. Groups with the federal preventive benefit also include benefits for women s health services with no additional co-payment. We have posted a brochure for the federal preventive benefits to the "References" area of our provider website. This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes. To determine a member has a grandfathered employer benefit or a federal benefit, verify a member s eligibility by logging into our secure provider website eligibility tool at or call our customer service department at (800) Business hours are Monday through Friday, 7 a.m. - 6 p.m. When verifying the member eligibility through the secure provider portal, scroll down to the bottom of the section Benefit Plan Information. Click on the ADDITIONAL RIDERS link. If one of the following riders appears after clicking on the link, the preventive benefits are grandfathered: Grandfathered Benefits Rider 2010 Benefit Changes Rider - GF Direct Pay 2010 Benefit Changes Rider - GF If a rider appears titled "Preventive Care Rider", the preventive benefit follows the federal benefit, and includes women s health services. Member Responsibility for Co-payment Members are expected to pay co-payments at the time service is provided. 51

55 Electronic Data Interchange (EDI) Claims Submitting claims via EDI has many advantages: 52 Reduced paperwork Savings on postage costs Immediate feedback on potential claim problems that affect payment Reduced processing time We encourage providers to submit claims electronically. Electronic Billing Specifications are available on the bcbsvt.com website, or if you have questions about electronic claims, please call Electronic Data Interchange (EDI) support at (800) , option 2, or us at General EDI Claim Submission Information BCBSVT and TVHP use several clearinghouses to accept claims. All transactions received need to be in an 837 HIPAA compliant format. To obtain a listing of clearinghouses please contact EDI Technical Support at (800) , option 2. Paper Claim Submission Claims not submitted electronically must be submitted on an CMS 1500 claim form. How to Avoid Paper Claim Processing Delays Please avoid the following to promote faster claim processing: Missing or invalid information Hand written claim forms Claim forms that are too light or too dark Poor alignment of data on the form Forms printed in non-black ink Attachments Attachments typically slow down the claim payment process and most are not needed for claim processing. Do not attach the following information to a paper claim: Medical documentation, unless instructed to do so Tax ID and address changes (See section One for full instructions) The following information must be attached to the applicable claims: Coordination of benefits (COB) information (primary carrier explanation of benefits) Descriptions for the following codes: NEC (not elsewhere classified), NOS (not otherwise specified) along with applicable and/or operative notes. Modifiers requiring documentation (such as modifier 22; refer to section 6 for full details) Coordination of Benefits (COB) COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan. The primary health care plan is responsible for paying the benefit amount allowed by the member s contract. The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan). In most cases, the total paid by both plans may provide payment up to, but not exceeding, BCBSVT and TVHP s allowed price. For BlueCard claims, refer to Section 7.

56 If COB applies, the primary carrier s Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed: Box 9: Other insured s name Box 9a-d: Other insured s policy or group number Box 11d: Marked yes unless Medicare or Medicaid is the primary insurer, then mark the no Box 29: Amount paid Note: For BCBSVT members, injuries which are work related are an exclusion of our certificates. BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment. We do however, allow consideration of services where worker s compensation has denied the claim as not work related. Medicare Supplemental and Secondary Claim Submission BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS). This means that the majority of paper submissions for these types of claims are not required. At this time, claims for Federal Employees (those with an alpha prefix of R ) and claims that qualify as mass adjustments do not crossover. This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim. The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT. How COBA works: In order for crossover to occur, BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member. The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member. Once the claim is matched to the BCBSVT membership file, the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider. The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer. Once BCBSVT receives the claim, it will process the claim according to the member s benefits and the provider contract and generate a remittance advice to the provider. If the Medicare Intermediary is unable to match a member s claim to a supplemental insurer s membership file, the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer. In this case, the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB). Quick Tips: When Medicare is primary, submit claims to your local Medicare Intermediary. After receipt of the explanation of payment from Medicare, review the indicators. If the indicator on the RA shows the claim was crossed-over, Medicare has submitted the claim to BCBSVT and the claim is in progress. If there is no crossover indicator on the explanation of benefits, submit the claim to BCBSVT with Medicare s EOMB. If you have any questions regarding the crossover indicator, contact the Medicare Intermediary directly. Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30-day mark, the complete claim will be returned requesting that it be resubmitted at the 30-day mark. Do not submit Medicare-related claims to BCBSVT before receiving an RA from Medicare. The one exception is statutorily excluded services or providers. Those can be submitted directly to BCBSVT using the modifier GY. For full details, see the modifier section below. Do not send duplicate claims. Check claim status on the BCBSVT secure provider site, or by calling Customer Service, before submitting a Medicare secondary or supplemental claim. If you are not checking the status, wait at least 30 days from the date of Medicare processing before resubmitting the claim. Special Billing Instructions for Rural Health Center or Federally Qualified Health Center: In most cases, you should not have to submit Medicare secondary/supplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS. Federal Employee Program (FEP) claims do not cross over at this time and require paper submission. If you do have a need to submit a Medicare secondary/supplemental claim to BCBSVT, submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB). 53

57 Providers who do not accept Medicare Assignment and are contracted with BCBSVT: In situations where the member has Medicare as primary and the provider does not accept Medicare Assignment, but contracts with BCBSVT, the following will occur: Members with supplemental insurance: Upon receipt of these claims, BCBSVT will consider benefits for any member liabilities that remain as reported by Medicare. These types of members are easily identified as they have a suffix at the end of their certificate number. Member with a BCBSVT policy after Medicare (referred to as secondary coverage): Upon receipt of these claims, BCBSVT will consider benefits for any outstanding balances and process using the BCBSVT guidelines. We will reimburse only those amounts that, when added to amounts received by other sources, equal 100% of the compensation that would otherwise be due. The provider must write off any balances between the allowed amount and the charged amount. Please refer to Section 1, Services where Medicare is primary, but provider (1) does not participate/accept assignment and (2) is contracted with BCBSVT, for information on what can be billed to the member, and for claim submission requirements. CMS 1500 Claim Form Instructions Go to CMS-1500 instructions.pdf for a link to complete instructions. Important Reminders Regarding Submission of the CMS 1500 To submit COB claims, attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9, 9a-d, 11d and 29. Only one service per line and only six lines of service are allowed on a claim form. List only one provider per claim. Individual rendering provider number must be indicated in item 24k of the form. Claim must be submitted within 180 days of service being rendered. Do not enter the amount of the patient s payment or the deductible in Item 29. Remittance Advice Remittance Advice (RA) are issued weekly to participating or in-network providers who submit claims. The RA s are designed to help providers identify claims that have been processed for their patients. The RA includes claims that are paid, denied or adjusted. We send a separate Remittance Advice ( RA) and payment check or electronic fund transfer (EPT)/direct deposit for each of the following benefit programs: Federal Employee Program (FEP) Indemnity, CBA Blue, Medicomp, Vermont Health Partnership (VHP) Medicare Supplemental Program The Vermont Health Plan (TVHP) BlueCard & Host Regional (NEHP) Remittance advices are available in either paper or electronic format (PDF or 835). Paper remits and checks are mailed using the US Postal Service. Electronic remits are also available on the secure area of the bcbsvt.com website. Please note: Paper remits are not mailed to practices/providers who receive electronic fund transfer (EFT)/direct deposit. See the reimbursement information in Section 1 for details on how to sign up for EFT/direct deposit. Electronic remits are retained for seven years. 54

58 Claim Status After initial submission, including Medicare crossover claims, wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial. After thirty (30) days there are several options to check the status of a claim: 1. Unlimited inquires may be made through the BCBSVT website, 2. See Section Two (2) of this manual for information on how to access claims information on the web. 3. Call one of the service lines listed in Section One (1) of this manual; or 4. Submit a Payment Inquiry Form Remittance Advice, Discount of Charge Reporting Due to our system calculations, services that price at a discount off charge report the allowed amount as the charged amount. The line is reported with a HIPAA adjustment code. Paper remits report a 45, and 835 s (I&P) report a 131. Example: If the provider bills in a charge of $ and the pricing is discount off charge (say 28%), the allowance is $ On the remit, the allowance will report $100; the payment (assuming no member liability) will reflect $72.00 and a provider write off of $ Resubmission of Returned Claims Returned claims are those that are returned to a provider either with a paper cover letter or on a paper/electronic error report informing the provider that the claim did not process through to a remittance advice if a vendor or clearinghouse submits a claim on a provider s behalf, the report is returned directly to the vendor and not the provider office. Claims could be returned for various reasons including, but not limited to: member unknown, NPI not on file, or incorrect place of service. For electronic submitters, a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected. For paper submissions, resubmit as a clean claim only after correcting the area of the claim that was in error. Never mark the resubmitted claims with any type of message as it will only result in a delay in processing. Corrected Claim A Corrected Claim is one which has processed through to a remittance advice, but requires a specific correction such as, but not limited to, change in units, change in date of service, billed amount or CPT/HCPCS code. Complete details on how to submit corrected claims are located on our provider website at under reference guides, then "Correct claim submission guidelines." Corrected Claims for Exchange Members within their grace period: Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed. They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice. If you do happen to submit a correct claim or adjustment, it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete. For full details on Exchange grace periods, see Grace Period for Individual Through the Exchange. BCBSVT Provider Claim Review A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate, amount of reimbursement, or payment policy (for example: denial for duplicate services which the provider believes were clinically appropriate). A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form. Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice date. All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form. The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies. 55

59 Member Confidential Communications BCBSVT members have the ability to file for a confidential communication process. Facilities and/or providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted. See Section 3 for full details. ClaimCheck BCBSVT utilizes McKesson ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT, Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims. This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD-10-CM) manuals. The ClaimCheck software is upgraded twice a year; in April and October. An advanced notice is posted to the news area of our provider website at advising of the upgrade date and any related details. These are the three most prevalent coding irregularities that we find: Unbundling: Two or more individual CPT or HCPCS codes that should be combined under a single code or charge. Mutually Exclusive: Two or more procedures that by practice standards would not be billed to the same patient on the same day. Inclusive Procedures: Procedures that are considered part of a primary procedure and not paid as separate services. Consistent application of these rules improves the accuracy and fairness of our payment of benefits. ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims. Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS); we will always be one version behind. In addition, ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value. RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions. Note: CPT codes and are not subjected to the ClaimCheck logic when billed in addition to the following evaluation and management codes: , , , or BCBSVT has made available to you Clear Claim Connection (C3). C3 is a web-based application that enables BCBSVT to disclose claims payment policies, rules and edit rationale to our physician network. Physicians can access any of this information via our secure provider website ( The system is designed to; increase transparency and help BCBSVT educate our physician community on conceivably complex medical payment policies. You can locate C3 as follows: 56 Go to the provider web area Sign into the secure provider website Go to link titled Clear Claim Connect (C3) There are two links: one for professional claim logic and one for outpatient claim logic; click on the applicable link. Providers can run claims through C3 for a determination of claims editing in advance of claim submission, or after claim submission to explain the logic. We encourage providers to use this tool to better understand the logic behind claims processing. Please remember, this is not tied to benefits, payment policies, medical policies, etc., and will only provide claim editing logic. In addition, the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing, so if you are inquiring about a service related to

60 another service, you will want to enter all services in the look-up tool. For example, if an office visit occurs a day earlier than a surgery, you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic. ClaimCheck Logic Review: A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims. Prior to filing for a ClaimCheck review, the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website. C3 will provide a full explanation of the logic behind the processing of the claim. A ClaimCheck Logic Review request may only be submitted in the following circumstance: A provider has locally or nationally recognized documentation that supports other possible logic. If a provider disagrees with the ClaimCheck logic, a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date. The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT. BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan. Note: A ClaimCheck Review of a specific claim should not be filed. If the claim was subject to extreme circumstances, the BCBSVT Provider Claim Review process set forth above should be followed. If, when reviewing a denial of a claim based on ClaimCheck, it is determined that a modifier or CPT code should be added/changed, the claim should be resubmitted as a Corrected Claim (as described above). BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases. Claim Specific Guidelines It is the intent and prerogative of BCBSVT to pay for necessary Medical, surgical, mental health, and substance abuse services, under our member contracts and in keeping with accepted and ethical medical practice. BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Association s Current Procedural Terminology (CPT). Diagnostic Coding must be according to the Internal Classification of Diseases (ICD 10 CM). The Plan(s) require CPT, HCPCS, and ICD-10-CM codes to ensure that claims are processed promptly and accurately. This section provides guidelines for use in submitting claims for services provided to BCBSVT, TVHP and BlueCard members (members from other Blue Plans). Topics are listed alphabetically. Notifications on revisions to this section will be posted to the provider website or published in FinePoints, the BCBSVT/TVHP newsletter for providers. Medical policies and benefit restrictions related to these and other medical services are available at or by calling your provider relations consultant. The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy, as well as policies documenting specific billing/coding guidelines and documentation requirements. The Payment Policy Manual overview and payment policies are available on our secure provider website at or by calling your provider relations consultant. BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in medical policy and/or payment policies. If an audit identifies instances of non-compliance with a medical policy and/or payment policy, BCBSVT reserves the right to recoup all non-compliant payments. 57

61 Acupuncture BCBSVT has a payment policy for acupuncture. The policy defines eligible, billable acupuncture services and how to bill for those services. Only those services defined in the payment policy are to be billed to BCBSVT. If other services are going to be rendered, the requirements of a waiver defined in Section 1 must be satisfied. When a waiver is on file non-eligible services can be billed directly to the member. Claims for non-eligible services shoudl not be billed to BCBSVT. Our payment policy for acupuncture is located on the secure provider portal at under BCBSVT policies, payment policies, acupuncture. Air Ambulance Must include the zip code of where the patient was picked up. Details for claim submission below. Paper Claims: Form Locators 39-41: AO (Numeric zero) in Value Codes section Form Locator 42: In the amount column indicate the 5-digit zip code in the dollar amount field where the patient is picked up: Submit the zip code in the following format 000ZZZZZ.00 Our system with truncate the leading zeros and post ZZZZZ.00, if the zip code has a leading zero (05602), it will reflect as (Electronic Claims): Loop 2300, Segment CLM05: A0 (Nurmeric zero) in Value Codes section Loop 2300, Segment CLM02: In the amount column indicate the 5-digit zip code in the dollar amount field where the patient is picked up: Submit the zip code in the following format 000ZZZZZ.00 Our system with truncate the leading zeros and post ZZZZZ.00, if the zip code has a leading zero (05602), it will reflect as NOTE: If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan. 58

62 Service Rendered Air Ambulance Services How to File (required fields) Point of pick-up ZIP Code: Populate item 23 on CMS 1500 Health Insurance Claim Form, with the 5-digit ZIP code of the point of pick-up For electronic billers, populate the origin information (ZIP code of the point of pick-up), in the Ambulance Pick-up Location Loop in the ASC X12N Health Care Claim (837) Professional. Where to File File the claim to the Plan in whose service area the point of pick-up ZIP code is located.* *BlueCard rules for claims incurred in an overlapping service area and contiguous county apply. Example The point of pick-up ZIP code is in Plan A service area. The claim must be filed to Plan A, based on the point of pickup ZIP code. Where Form CMS-1450 (UB- 04) is used for air ambulance services not included with local hospital charges, populate Form Locators 39-41, with the 5-digit ZIP code of the point of pick-up. The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB-04 Data Specifications Manual. Form Locators (FL) Code: AO (Special ZIP code reporting), or its successor code specified by the National Uniform Billing Committee. Value: Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulance. For electronic claims, populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional. Allergy For injection of commercially prepared allergens, use the appropriate CPT code for administration. For codes indicating more than test, the specific number of tests should be indicated on the claim form in item 24g. 1 unit = 1 test. Use the appropriate CPT/HCPCS drug code if billing for the injected material. 59

63 Ancillary Claim for BlueCard (defined as Durable Medical Equipment, Independent Clinical Laboratory and Specialty Pharmacy) You must file ancillary claims to the Local Plan, which is the Plan in whose service area the ancillary services are rendered, defined as follows: Independent Clinical Laboratory* Durable Medical Equipment Specialty Pharmacy* The Plan in whose service area the specimen was drawn or collected *(Place of Service 81 only) The Plan in whose service area the equipment was shipped to or purchased at a retail store The Plan in whose service area the ordering physician is located *(Pharmacy Specialty only) All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan. The following information is required on all ancillary claim submissions. If this information is missing, we will return or reject these claims. Ancillary Claim Type Independent Clinical Laboratory Durable Medical Equipment Durable Medical Equipment Durable Medical Equipment Speciality Pharmacy Local Plan Identifier Referring Provider NPI Referring Provider NPI* If Place of Service = Home, Patient/ Member Address If Place of Service Home, Service Facility Location or Billing Provider Location Referring Provider NPI CMS 1500 Box/ Description 17B 17B Loop on 837 Electronic Submission 2310A 2310A 5 or CA or 2010BA 32 or C or 2010AA 17B 2310A Not used to identify Local Plan for ancillary claim processing, however required on all DME claims to support medical record processing. It is important to note that if you have a contract with the local Plan as defined above, you must file claims to the local Plan, and they will process as participating/network provider claims. If you do not have a contract with the local Plan, you must still file claims with the local Plan, but we will consider non-participating/out-of-network claims. 60

64 Anesthesia Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance that is, when the patient is safely placed under post-anesthesia supervision. Time during which the anesthesiologist, and/or certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non-billable time. Services involving administration of anesthesia should be reported using the applicable anesthesia five-digit procedure codes ( ) and, if applicable, the appropriate HCPC National Level II anesthesia modifiers and/or anesthesia physical status (P1 P6) modifiers as noted below. An anesthesia base unit value should not be reported. Time units should be reported with 1-unit for every 15 minute interval. Time duration of 8 minutes or more constitutes an additional unit. Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing: (time units + base unit value) x anesthesia coefficient. Base unit values (BUVs) will automatically be included in the reimbursement. The following table identifies the source of each component that is utilized in the anesthesia pricing method. Component Time Units Base Unit Value (BUV) Anesthesia Coefficient Source of Information Submitted on the claim by the provider Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist and/or certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services. The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs), thus, from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists. CRNA Modifiers (please note, these modifiers should always be billed in the first position of the modifier field) Modifier -QS -QX -QZ Description Monitored anesthesia care services CRNA service: with medical direction by a physician CRNA service: without medical direction by a physician BCBSVT/TVHP Business Rules Informational Modifier use will not impact reimbursement Allows 50% of fee schedule payment based on the appropriate unit rate Allows 100% of fee schedule payment based on the appropriate unit rate 61

65 Anesthesiologist Modifiers (please note, these modifiers should always be billed in the first position of the modifier field) Modifier -AA -QK -QS -QY Description Anesthesia service performed personally by anesthesiologist Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals Monitored anesthesia care services Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist BCBSVT/TVHP Business Rules Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure, 100% payment for the services of each provider is allowed. Anesthesiologist would report AA and CRNA QZ. Allows 50% of fee schedule payment based on the appropriate unit rate Informational Modifier use will not impact reimbursement Allows 50% of fee schedule payment based on the appropriate unit rate BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision. Medical Direction Medical direction occurs when an anesthesiologist is involved in two, three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist. The physician should: 1. perform a pre-anesthesia examination and evaluation; 2. prescribe the anesthesia plan; 3. personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence, if applicable; 4. ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist; 5. monitor the course of anesthesia administration at intervals; 6. remain physically present and available for immediate diagnosis and treatment of emergencies; and 7. provide indicated post-anesthesia care. If one or more of the above services are not performed by the anesthesiologist, the service is not considered medical direction. 62

66 Medical Supervision Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures. Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist. This might occur in cases when the anesthesiologist: Left the immediate area of the operating suite for more than a short duration; Devotes extensive time to an emergency case; or Was otherwise not available to respond to the immediate needs of the surgical patients. Example: An anesthesiologist is directing CRNAs during three procedures. A medical emergency develops in one case that demands the anesthesiologist s personal continuous involvement. If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients, medical direction ends in those two cases. Medical Supervision by a Surgeon: In some small institutions, nurse anesthetist performance is supervised by the operating provider (i.e., surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists. Supervision services provided by the operating physician are considered part of the surgical service provided. Anesthesia Physical Status Modifiers (please note, these modifiers should always appear in the second modifier field) Modifier P1 P2 P3 P4 P5 P6 Description A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes BCBSVT/TVHP Business Rules Informational Modifier use will not impact reimbursement Informational Modifier use will not impact reimbursement Informational Modifier use will not impact reimbursement Informational Modifier use will not impact reimbursement Informational Modifier use will not impact reimbursement Informational Modifier use will not impact reimbursement Electronic billing of anesthesia: Electronic billing can either be in minutes or 8-15 unit increments. The appropriate indicator would need to be used to advise if the billing is units or minutes. Please refer to our online companion guides for electronic billing for specifics. If billing minutes, our system edits require that 16 or more are indicated. If 15 minutes or less, the claim is returned to the submitter. Claims for 8-15 minutes of anesthesia must be billed on paper. Anesthesia reimbursement is always based on unit increments; 63

67 therefore, electronic claims submitted as minutes are translated by the BCBSVT system into 8-15 minute unit increments. Time units are translated; 1-unit for every 8-15 minute interval. Time duration of 8 minutes or more constitutes an additional unit. Paper billing of anesthesia: Anesthesia services billed on paper can only be billed in unit increments (1- unit for every 8-15 minutes interval, time duration of 8-15 minutes constitutes an additional unit). If your claim does not qualify for at least 1-unit (is less than 8 minutes), it should not be submitted to BCBSVT. BlueCard Claims See Section 7 for details Bilateral Procedures For bilateral surgical procedures when there is no specific bilateral procedure code, use the appropriate CPT code for the first service, and use the same code plus a modifier 50 for the second service. Biomechanical Exam Use office visit codes for biomechanical exams. Breast Pumps Specific guidelines for benefits and billing are available on our provider website at under Breast pumps, how to determine benefits. Computer Assisted Surgery/Navigation See Robotic & Computer Assisted Surgery/Navigation later in this section for full details. Dental Anesthesia: Effective January 1, 2018 there is a change to dental anesthesia codes; D9222 and D9239 are new and D9223 and D9243 have been revised: New or HCPCS Code Description Revised New D9222 Deep sedation/general anesthesia - first 15 minutes New D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes Revised D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment Revised D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes. Example of how services should be billed: 64 Deep sedation/general anesthesia for 1 hour: D unit (equals 15 minutes) D units (equals 45 minutes) Intravenous moderate (conscioius) sedation/analgesia for 1 hour: D unit (equals 15 minutes) D units (equals 45 minutes) Time units* need to be reported with 1-unit for every 15 minute interval. Time duration of 8 minutes or more constitutes an additional unit. Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient, therefore, it is very important that you bill accordingly on one claim line. Base unit values (BUVs) will automatically be included in the reimbursement.

68 Example: 47 minutes of deep sedation was provided to a patient. Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions*). *If billing electronically, services can either be in minutes or 8-15 unit increments. The appropriate indicator must be used to advise if the billing is units or minutes. Please refer to our online companion guides for electronic billing for specifics, or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing. Dental Care FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost. To learn more about FEP dental coverage and claim submission requirements, refer to Section 9 FEP. Health Care Exchange members have benefits available for Pediatric Dental. These members are identified by an alpha prefix of ZII or ZIG and are age 21 or under. They are covered through the end of the year of their 21st birthday. Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy. The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted. It has two sections; Part A and Part B. The first section, Part A" defines all the services and requirements of the medical component for dental. The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers. Prior approval requests and claim submissions are sent directly to BCBSVT. The second section, Part B" defines all the services and requirements for the pediatric dental benefits. The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers. Prior approval requests and claim submissions are sent directly to CBA Blue. Note: CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B. Pretreatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterhead. If services incorporate both Part A and Part B services and prior approval is required, the prior approval needs to be submitted to BCBSVT. We will coordinate with CBA Blue for proper processing. Claims can be split out and sent to both, or if that is not possible, you may submit directly to BCBSVT and we will coordinate the processing. Diagnosis Codes BCBSVT claims process using the first diagnosis code submitted. If you receive a denial related to a diagnosis code on a BCBSVT claim, and there is another diagnosis on the claim that would be eligible, you do not need to submit a corrected claim. Just contact our customer service team either by phone, , fax or mail and they will initiate a review and/or adjustment. Or, if the diagnosis is truly in the wrong position, you may submit a corrected claim updating the placement of the diagnosis. For BlueCard claims, we send all reported diagnosis code(s) to the member s Plan. If you wish to change the order of the diagnosis codes, you must submit a corrected claim. This corrected claim adjustment may or may not affect the benefit determination. Diagnostic Imaging Procedures BCBSVT has a payment policy for Multiple Procedure Payment Reduction - Diagnostic Imaging Procedures. The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session. Our payment policy for Multiple Procedure Payment Reduction - Diagnostic Imaging Procedures is located on the secure provider website at under BCBSVT Policies/Payment Policies/Multiple Procedure Payment Reduction - Diagnostic Imaging Procedures. 65

69 Drugs Dispensed or Administered by a Provider (other than pharmacy) Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s). This requirement applies to drugs in the following categories: administrative miscellaneous investigational radiopharmaceuticals drugs administered other than by oral method chemotherapy drugs select pathology laboratory temporary codes The requirement does not apply to immunization drugs or to durable medical equipment. Acceptable values for the NDC Units of Measurement Qualifiers are as follows: Unit of Measure F2 GR ME ML UN Description International Unit Gram Milligram Milliliter Unit BCBSVT has the flexibility to accept the unit of measure reported in any nationally-excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table. Please refer to our online CMS (item number 24a and 24D), UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 1.11, NDC) for full billing details. We have posted a National Drug Code (NDC) Provider Tool to our secure provider website. It is intended to assist practices in determining the unit of measure that needs to be reported to BCBSVT. BCBSVT updates the NDC codes and pricing in February and August. We require the submission of the claims to align with the current code set. Durable Medical Equipment DME rentals require "From" and "To" dates on claims, but the dates cannot exceed the date of billing. Evaluation and Management reminder 66

70 Current Procedural Terminology (CPT) guidelines recognize seven components, six of which are used in defining the levels of evaluation and management services. These components are: History; Examination; Medical decision making; Counseling; Coordination of care; Nature of presenting problem; and lastly Time. The first three of these components are considered the key components in selecting a level of evaluation and management services. The next three components are considered contributory factors in the majority of encounters. Although counseling and coordination of care are important evaluation and management services, these services are not required at every patient encounter. The final component, time, is provided as a guide; however, it is only considered a factor in defining the appropriate level of evaluation and management when counseling and/or coordination of care dominates the physician/patient and/or family encounter. Time is defined as face-to-face time; such as obtaining a history, performing and examination or counseling the patient. CPT provides a nine-step process that assists in determining how to choose the most appropriate evaluation and management code. We apply this process when auditing medical and billing records, and encourage all practices/providers to become familiar with the nine step process. Remember however, the most important steps, in terms of reimbursement and audit liability, are verifying compliance and documentation. If your practice utilizes a billing agent, it is still the practice s responsibility to make sure correct coding of claims is occurring. Please refer to a CPT manual for full details on proper coding and complete documentation. Flu Vaccine and Administration BCBSVT contracted providers, facilities and home health agencies cannot bill members up front for the vaccine or administration. The rendering provider, facility or home health agency must submit the claim for services directly to BCBSVT. Every member who receives a flu shot must be billed separately. BCBSVT does not allow for roster billing or billing of multiple patients on one claim. Both an administration and a vaccine code can be billed for the service. For billing of State-supplied vaccine/toxoid, please refer to instructions further down in this section. Habilitative Services Most BCBSVT members have benefits available for habilitative services. Habilitative services, including devices, are provided for a person to attain a skill or function never learned or acquired due to a disabling condition. When providing habilitative services for physical medicine, occupational or speech therapy a modifier- SZ must be reported, so services will accumulate to the correct benefit limit. All other services for habilitative do not have any special billing requirements. Home Infusion Therapy (HIT) Drug Services HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy). Please refer to that section of the manual for full details. HIT providers who are on the community home infusion therapy fee schedule must bill procedure code (Synigis-RSV) using the Average Wholesale Price (AWP). If you have questions, please contact your provider relations consultant at (888)

71 Hospital Acquired Condition See Never Events, Hospital Acquired Conditions and Preventable Medical Errors in this section for full details. Hub and Spoke System for Opioid Addiction Treatment (Pilot Program) BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment. The policy defines what the pilot program is, benefit determinations and billing guidelines and documentation. Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at under BCBSVT policies, payment policies, Hub and Spoke. Immunization Administration CPT codes and should only be reported when a physician or other qualified health care professional provides face-to-face counseling to the patient and family during the administration of a vaccine. This face-to-face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parents/caregiver. Proper signatures are also required to verify level of provider qualification. Documentation is to be stored in the patient s medical records. Qualified health care professional does not include auxiliary staff, such as licensed practical nurses, nursing assistants, and other medical staff assistants. Each vaccine is administered with a base (CPT 90460) and an add-on code (CPT 90461) when applicable. CPT codes and allows for billing of multiple units when applicable. Single line billing examples with counts Example A: Single line billing, multiple vaccines with combination toxoids Line CPT-4 Description Unit Count Human papilloma virus vaccine quadriv 3 dose im Immunization Administration 18 yr any route 1st vac/toxoid 1 1 Example B: Single line billing, multiple vaccines with combination toxoids Line CPT-4 Description Unit Count Measles mumps rubella 1 varicella vacc live subq Immunization Administration through 1 18 yr any route 1st vac/toxoid Immunization Administration through 18 yr any route ea addl vac/toxoid 3 68

72 Example C: Single line billing, multiple vaccines with combination toxoids Line CPT-4 Description Unit Count Dtap-hib-ipv vaccine im Pneumococcal conj 1 vaccine 13 valent im Rotavirus vaccine pentavalent 1 3 dose live oral Immunization Administration through 3 18 yr any route 1st vac/toxoid Immunization Administration through 18 yr any route ea addl vac/toxoid 4 If a patient of any age presents for vaccinations, but there has been no face-to-face counseling, the administration(s) must be reported with codes See Ancillary Claims for BlueCard, earlier in this section. Use the appropriate CPT code for administration of the injection. If applicable, submit the appropriate CPT and/or HCPCS code for the injected material. Inpatient Hospital Room and Board, Routine Services, Supplies and Equipment: BCBSVT has a payment policy for the Inpatient Hospital Room and Board, Routine Services, Supplies and Equipment. The policy provides a description, benefit determinations and billing guidelines and documentation. Our payment policy for Inpatient Hospital Room and Board, Routine Services, Supplies and Equipment is located on the secure provider portal at under BCBSVT policies, payment policies, Inpatient Hospital Room and Board, Routine Services, Supplies and Equipment. Incident To This is also referred to at times as supervised billing and is not allowed by BCBSVT. Providers who render care to our members must be licensed, credentialed and enrolled. Exceptions are: Physical Therapy Assistants, Occupational Therapy Assistants and Mental Health Trainees who meet the requirements defined in our policies. Locum Tenens Must be enrolled (See Section 1 for details.) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J. Laboratory Handling Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory, and the claim for the laboratory work is submitted by the physician. Use place of service 11 in CMS 1500 item 24b. Laboratory Services (self-ordered by patient): We require all laboratory services be ordered by a qualified health care provider. If a patient has self-ordered laboratory services(s), claim(s) cannot be billed to BCBSVT. The member is financially liable and must be billed directly. 69

73 Mammogram (screening) and screening additional views BCBSVT has very specific coding requirements for screening mammograms and screening additional views ("screening call backs") with a Breast Imaging Report and Data System (BI-RADS) score of 0 (zero). For an initial, screening mammography, bill the following codes, which will process at no member cost share*: CPT/HCPCS Code 77067, 77063, G0202 (Use Modifier -52 to report a unilateral exam) Primary ICD-10 Reporting Z00.00, Z00.01, Z12.31, Z12.39, Z80.3, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13 For additional screening views or "call backs" when the initial screening mammography results in a Bi-RADS score of 0**, the following codes must be used to ensure first-dollar coverage. You do not need to include any additional modifiers to indicate screening services. CPT/HCPCS Code 77067, 77063, G0202 (Use Modifier -52 to report a unilateral exam) Primary ICD-10 Reporting R92.2, R92.8 While the national preventive care guidelines recommend screening mammography every one to two years, BCBSVT does not require that members wait at least 365 days between medically necessary, screening mammograms to access first-dollar coverage***. * The Federal Employee Program and BlueCard benefits may not provide first-dollar coverage. For details on eligible mammography services, contact the appropriate customer service team or Blue Plan. ** The BI-RADS system was developed by the American College of Radiology as a way to score all mammograms. See cancer/breast-cancer/screening-tests-and-earlydetection/mammograms/understanding-your-mammogram-report.html for more information. *** When applicable. Member must have a benefit program that includes the Affordable Care Act, first dollar preventive benefits. Maternity If a physician provides all or part of the antepartum patient care but does not perform delivery, the following CPT codes are to be used: Antepartum Care for visit 1-3, use appropriate Evaluation and Management code applicable for each visit. Antepartum Care for visit 4-6, use CPT code This code and reimbursement is inclusive of all 3 visits (visits 4 6). Antepartum Care for visit 7 on, use CPT code This code and reimbursement is inclusive of visits 7 forward. For other services, use appropriate CPT coding. Medically Unlikely Edits BCBSVT follows the Centers for Medicare & Medicaid Services' (CMS) National Correct Coding Initiative (NCCI) guidelines. 70

74 This program is administered by our partner, Cotiviti. At this time application of MUE is retrospective and is not processed through the ClaimCheck system. Modifiers The following payment rules apply when using these modifiers: Modifier AS (physician assist, nurse practitioner or clinical nurse specialist services for assistant surgery) 25% of allowed charge and 12.5% of allowed charge for each secondary procedure. Modifier GY (item or service statutorily excluded; does not meet the definition of any Medicare benefit for non-medicare insurers, and is not a contracted benefit). The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement. The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare. BlueCard claims with a GY modifier need to be submitted directly to BCBSVT. The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the member s benefits. In addition to the GY modifier, the claim submission (paper or electronic) must indicate that Medicare is the member s primary carrier. Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the member s Blue plan. Instead, either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan, BCBSVT. We do this so that our local Plan pricing is applied. Services without the GY process using Medicare s allowance; services with the GY needs ours. These claims will be returned or rejected with denial code 109 (claim not covered by this payer/contractor) on the 835 or paper remits. The paper remits will provide further information by way of remark code N418 "Misrouted claim. See the payer s claim submission instructions." When submitting Medicare previously processed claims directly to BCBSVT, include the original claim (with all lines, including those without the GY modifier), and the Explanation of Medicare Benefits. Lines that have previously paid through the member s Blue Plan will deny as duplicate, and the lines with the GY modifiers will be processed according to the benefits the member has available. Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed. This will report through to the remittance advice and report a HIPAA denial reason code 246 This non-payable code is for required reporting only." Modifier QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) 50% of fee schedule payment based on the appropriate unit rate. Modifier QX (CRNA service: with medical direction by a physician) 50% of fee schedule payment based on the appropriate unit rate Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist) 50% of fee schedule payment based on the appropriate unit rate. Modifier SZ (habilitative services) - When providing habilitative services for physical medicine, occupational or speech therapy a modifier-sz must be reported, so services will accumulate to the correct benefit limit. Modifier 54 (surgical care only) 85% of allowed charge for primary surgical procedure. Modifier 55 (postoperative management only) 10% of allowed charge for primary surgical procedure. Modifier 56 (preoperative management only) 5% of allowed charge for primary surgical procedure. Modifier 81 (minimum assistant surgeon) 10% of allowed charge and 5% of allowed charge for each secondary procedure. Modifier 82 (assistant surgeon, when qualified resident surgeon is not available) 25% of allowed charge and 12.5% of allowed charge for each secondary procedure. Modifier 22 requires that office and/or operative notes be submitted with the claim. Claims without office and/ or operative notes, if payable, reimburse at a lower level. Please refer to -22 Modifier Payment Policy on the secure provider website located under under BCBSVT policies, payment policy for complete guidelines. Modifiers -80, -82, and AS are only allowed when a surgical assistant assists for the entire surgical procedure. Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure. Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure. Modifiers for Anesthesia, please refer to Anesthesia section for specifics on usage. 71

75 National Drug Code (NDC) The reporting of an NDC is required for some claim types. Refer to the section in this manual titled: Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy. Never Events, Hospital Acquired Conditions and Preventable Medical Errors The BCBSVT Quality Improvement Policy, Never Events, Hospital Acquired Conditions and Preventable Medical Errors Reporting and Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions, investigations, coding requirements and audits. The policy is located on the secure provider portal at under BCBSVT Policies, then the Quality Improvement link. Or, you can call your provider relations consultant for a paper copy. Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVT s quality improvement coordinator at QualityImprovement@bcbsvt.com. The needs to include the patient s name, BCBSVT ID number, date of service involved, type of service, name of attending physician and the name of person to contact if there are questions. Claims for these services should be submitted to BCBSVT/TVHP for inpatient claims. The present on admit indicator must be populated accordingly. BCBSVT will not reimburse for any of the related charges. The provider and/or facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event. Not elsewhere classified (NEC) Not otherwise classified (NOS) Providers should always bill a defined code when one is available. If one is not available, use an unlisted service (NEC or NOS), provide a description of the service along with office and/or operative notes. The note must accompany the original claim. Physical Therapy Assistant (PTA) PTA s are expected to practice within the scope of their license. PTA's do not need to enroll or credential with BCBSVT to be eligible. Their services must be directly supervised by a Physical Therapist. The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given. Medical notes must be signed off by the supervising therapist. Claims for PTA services must be submitted under the supervising Physical Therapist s rendering national provider identifier. Observation Services BCBSVT has a payment policy for Observation Services. The policy provides a description, eligible and ineligible services, and billing guidelines. Our payment policy for Observation Services is located on the secure provider portal at under BCBSVT policies, payment policies, Observation Services. Occupational Therapy Assistant (OTA) OTA s are expected to practice within the scope of their license. PTA's do not need to enroll or credential with BCBSVT to be eligible. Their services must be directly supervised by an Occupational Therapist. The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given. Medical notes must be signed off by the supervising therapist. Claims for OTA services must be submitted under the supervising Occupational Therapist s rendering national provider identifier. Place of Service 03 - used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide used for office setting or services provided in a school setting or school-owned infirmary when the provider is not contracted with the school to provide the services. 72

76 Pre-Operative and Post-Operative Guidelines: Some surgical procedures have designed pre and/or post-operative periods. For those procedures (and associated timeframes) if an evaluation and management service is reported, the service will deny. To determine if a surgery qualifies for pre and/or post-operative periods, use the clear claim connect (C3) tool on the secure provider website. Enter in the surgical code being performed along with the evaluation management code. Make sure you indicate on each service line the specific date it will be or has been performed. Or, we have a complete listing on the secure provider website under the resource center, clinical manuals, pre and post-operative manual. Preventable Medical Errors: See Never Events, Hospital Acquired Conditions and Preventable Medical Errors earlier in this section for full details. Provider-Based Billing BCBSVT does not allow for provider-based billing (i.e. billing a facility charge in connection with clinic services performed by a physician or other medical professional). Our payment policy for Provider-Based Billing is located on the secure provider portal at under BCBSVT policies, payment policies, provider based billing. Robotic & Computer Assisted Surgery/Navigation BCBSVT does not provide benefits for Robotic & Computer Assisted Surgery/Navigation. Our payment policy for Robotic & Computer Assisted Surgery/Navigation is located on the secure provider portal at com under BCBSVT policies, payment policies, Robotic & Computer Assisted Surgery/Navigation. S Codes Submit using the appropriate CPT/HCPCS code. Charges submitted with an unspecified CPT code (99070) will be denied as non-covered. Specialty Pharmacy Claims See Ancillary Claims for BlueCard, earlier in the section. State Supplied Vaccine/Toxoid Must be submitted for data reporting purposes. Use the appropriate CPT code for the vaccine/toxoid and the modifier SL (state supplied vaccine) and a charge of $0.00. If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount, a charge of $0.01 can be used. Subsequent Hospital Care Subsequent hospital care CPT codes (99231, 99232, 99233) are per day services and need to be billed line by line. Supervised Billing This is also referred to at times as "incident to" and is not allowed by BCBSVT. Providers who render care to our members must be licensed, credentialed and enrolled. Exceptions are: Physical Therapy Assistants, Occupational Therapy Assistants and Mental Health Trainees who meet the requirements defined in our policies. Supplies Submit using the appropriate CPT/HCPCS code. Charges submitted with an unspecified CPT code (99070) will be denied as non-covered. Surgical Assistant Benefits for one assistant surgeon may be provided during an operative session. In the event that more than one physician assists during an operative session, the total benefit for the assistant will not exceed the benefit for one. Please use appropriate CPT coding. 73

77 Not all surgeries qualify for a surgical assistant. To determine if the assist you are providing is eligible for consideration, use the clear claim connect (C3) tool on the secure provider website, or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center, clinical manuals, assistant surgeon manual. Surgical Trays When billing for a surgical tray, members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray. No modifiers or units are allowed. Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate, and when the procedure is performed in a physician s office rather than a separate surgical facility. To determine if a surgical tray is eligible for consideration, use the clear claim connect (C3) tool on the secure provider website. Enter in the services being performed along with the surgical tray code. Alternately, you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center, clinical manuals, surgical tray manual. Telemedicine BCBSVT has a payment policy for telemedicine. The policy defines eligible telemedicine services and how the services need to be billed. Our payment policy for telemedicine is located on the secure provider portal at under BCBSVT policies, payment policies, telemedicine. Unit Designations Each CPT & HCPCS code has a unit designation. The designation is single or multiple. If the code is designated as single unit and more than one services was provided, each service needs to be billed on its own line. If a code has a multiple unit designation and more than one service was provided, you need to bill on a single line and indicate the number of units provided. We have a list of codes and their unit designations available on our provider website at The list is not all inclusive. If you do not locate your code on the list, contact our customer service team and they will be able to advise you. The unit designation list is updated quarterly to align with the AMA s updates for new, deleted and revised codes. Urgent Care Clinic BCBSVT has a payment policy for Urgent Care Clinics. The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed. Our payment policy for Urgent Care Clinics is located on the secure provider portal at under BCBSVT policies, payment policies, Urgent Care Clinics. Vision Services Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them. We have created quick overview documents that define the services that are eligible, and indicate where claims need to be submitted. The overview documents are located on our secure website under resources, reference guides, vision services. 74

78 Section 7 The BlueCard Program Makes Filing Claims Easy Introduction As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross and/or Blue Shield Plans, and who travel or live in Vermont. This manual is designed to describe the advantages of the program, while providing you with information to make filing claims easy. This manual offers helpful information about: Identifying members Verifying eligibility Obtaining pre-certifications/pre-authorizations Filing claims Who to contact with questions What is the BlueCard Program? a. Definition The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Plan s area to receive all the same benefits of their contracting BCBS Plan, including provider access and discounts on services negotiated by the local plans. The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing. The program allows you to submit claims for patients from other Blue Plans, domestic and international, to BCBSVT. BCBSVT is your sole contact for claims payment, problem resolution and adjustments. b. BlueCard Program Advantages to Providers The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans, including international Blue Plans, directly to BCBSVT. BCBSVT will be your one point of contact for all of your claims-related questions. BCBSVT continues to experience growth in out-of area membership because of our partnership with you. That is why we are committed to meeting your needs and expectations. In doing so, your patients will have a positive experience with each visit. c. Accounts Exempt from the BlueCard Program The following claims are excluded from the BlueCard Program: stand-alone dental prescription drugs the Federal Employee Program (FEP) How Does the BlueCard Program Work? How to Identify Members a. Member ID Cards 75

79 When members of another Blue Plan arrive at your office or facility, be sure to ask them for their current Blue Plan membership identification card. The main identifier for out-of-area members is the alpha prefix. The ID cards may also have: PPO in a suitcase logo, for eligible PPO members Blank suitcase logo Important facts concerning member IDs: A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters, up to 17 positions total. This means that you may see cards with I.D. numbers between 6 and 14 numbers/letters following the alpha prefix. Do not add/delete characters or numbers within the member ID. Do not change the sequence of the characters following the alpha prefix. The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Plan. Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage. Member ID cards may have different alpha prefixes for each type of coverage. As a provider servicing out-of-area members, you may find the following tips helpful: Ask the member for the current I.D. card at every visit. Since new I.D. cards may be issued to members throughout the year, this will ensure tha you have the most up-to-date information in your patient s file. Verify with the member that the number on the I.D. card is not his/her Social Security Number. If it is, call the BlueCard Eligibility line at (800) 676-BLUE (2583) to verify the I.D. number. Make copies of the front and back of the member s I.D. card and pass the key information on to your billing staff. Remember: Member I.D. numbers must be reported exactly as shown on the I.D. card and must not be changed or altered. Do not add or omit any characters from the member s I.D. numbers. Alpha Prefix The three-character alpha prefix at the beginning of the member s identification number is the key element used to identify and correctly route claims. The alpha prefix identifies the Blue Plan or national account to which the member belongs. It is critical for confirming a patient s membership and coverage. The prefix is followed by the member identification number. It can be any length, and can consist of all numbers, all letters or a combination of both letters and numbers. To ensure accurate claim processing, it is critical to capture all ID card data. If the information is not captured correctly, you may experience a delay with the claim processing. Please make copies of the front and the back of the I.D. card, and pass the key information to your billing staff. MEMBER NAME CHRIS B. HALL BS PLAN 915 RESTAT 0451 BC PLAN 415 IDENTIFICATION NUMBER XYZ XYZ GROUP NUMBER The three-character alpha prefix. 76

80 The suitcase logo may appear anywhere on the front of the card.. MEMBER NAME CHRIS B. HALL BS PLAN 915 RESTAT 0451 BC PLAN 415 IDENTIFICATION NUMBER XYZ XYZ GROUP NUMBER PREADMISSION REVIEW REQUIRED Sample ID Cards Occasionally, you may see identification cards from foreign Blue members, including foreign Blue members living abroad. These ID cards will also contain three-character alpha prefixes. Please treat these members the same as domestic Blue Plan members. NOTE: The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the U.S. Sample Foreign ID Cards If you are unsure about your participation status, call BCBSVT. 77

81 b. Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members, reduce employer costs, and change consumer health care purchasing behavior. Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools, provider and network information, and financial incentives. Members who have CDHC plans often carry health care debit cards that allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). Some cards are stand-alone debit cards to cover out-of-pocket costs, while others also serve as a member ID card with the member ID number. These debit cards can help you simplify your administration process and can potentially help: Reduce bad debt Reduce paper work for billing statements Minimize bookkeeping and patient-account functions for handling cash and checks Avoid unnecessary claim payment delays The card will have the nationally recognized Blue logos, along with a major debit card logo such as MasterCard or Visa. Sample stand-alone Health Care Debit Card Sample Combined Health Care Debit Card and Member ID Card The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (i.e. copayment). With the health debit cards, members can pay for co-payments and other out-of-pocket expenses by swiping the card through any debit card swipe terminal. The funds will be deducted automatically from the member s appropriate HRA, HSA or FSA account. Combining a health insurance ID card with a source of payment is an added convenience to members and providers. Members can use their cards to pay outstanding balances on billing statements. They can also use their cards via phone in order to process payments. In addition, members are more likely to carry their current ID cards, because of the payment capabilities. 78