Blue Medicare Advantage HMO SM

Transcription

1 PROVIDER ORIENTATION Blue Medicare Advantage HMO SM Revised 10/06/2017

2 Blue Medicare Advantage County Service Areas Austin Area Counties Houston Area Counties Rio Grande Valley Area Counties El Paso Area County Bastrop Burnett Caldwell Hays Lee Williamson Chambers Fort Bend Hardin Harris Jefferson Liberty Montgomery Orange Cameron Hildago Webb Willacy El Paso San Antonio Area Counties Effective 1/1/2018 Atascosa, Bandera, Bexar, Comal, Kendall, Medina & Wilson County

3 Benefit Plan Overview Please visit our website at bcbstx.com or contact Customer Service number for Blue Medicare Advantage (HMO) members or providers is: (877) Customer Service numbers can be found on the back of the Member s ID card

4 Online Access Overview Go to

5 Continue Online Access Overview Go to

6 Online Helpful Information Links Please review the following link to see helpful information as indicated below:

7 Sample Member ID Card 3 letter alpha prefix: ZGJ Please note the phone number for Blue Medicare Advantage is different from the other BCBSTX products Customer Service numbers can be found on the back of the Member s ID card

8 Pre-Authorization Requirements Initiating Pre-Authorizations Blue Medicare Advantage Customer Service (877) Online via iexchange through BCBSTX website Link for pre-authorization list:

9 Pre-Authorization Requirements list for Medical/Surgical Refer to the complete list of Preauthorization requirements on bcbstx.com/provider/network/bma_hmo.html All Air Ambulance All Network Exceptions All Organ Transplants Blepharoplasty Botox Injections DME, Medical Supplies, Orthotics and Prosthetics greater than $2,500 per unit All Home Health Care and Hospice All Acute Inpatient Stays Laboratory Genetic Outpatient All Long term Acute Care All Inpatient Rehab Medical Outpatient see list of Codes Outpatient Dignostic Test see list of codes All Skilled Nursing Facility Stays Surgical Inpatient/Outpatient see list for codes Specialty Drugs see list for codes Please note Effective 6/1/17, BCBSTX has contracted with evicore to provide Utilization Management for certain specialized clinical services. Refer to the evicore webpage on bcbstx.com/provider under Clinical Resources for more information.

10 evicore Pre-Authorization Program Blue Cross and Blue Shield of Texas (BCBSTX) has contracted with evicore healthcare (evicore)* to provide certain utilization management preauthorization services. For a detailed list of CPT codes that require preauthorization through evicore for Blue Medicare Advantage HMO and Blue Medicare Advantage PPO effective 6/1/17, or access the listing on the BCBSTX Medicare evicore implementation site and select the Medicare CPT codes list based on the type of service being rendered.

11 Claims & Billing Information Electronic Claims: Submit claims electronically using Availity Payor ID #66006 If you must file paper claims, file to: Blue Cross Medicare Advantage C/O Provider Services P.O. Box 3686 Scranton, PA Filing deadline is 180 days from date of service/discharge or as allowed per contract

12 Cont. Claims & Billing Information Payments and remittance advice for Blue Medicare Advantage (HMO) members will be paid in the same method as your existing BCBSTX business, i.e., check or Electronic Funds Transfer (EFT). Electronic Remittance Advice (RA) and Remittance Advice (RA) has plan code as of September to identify products, Blue Medicare Advantage (HMO) code is MCH. The Blue Medicare Advantage (HMO) Customer Service phone number is the initial contact number for questions and inquiries into payment questions.

13 Claims Disputes and Medical Grievances & Appeals Claims Disputes Should be submitted to: Blue Medicare Advantage HMO P.O. Box 4555 Scranton, PA Medical Grievances & Medical Coverage Determinations & Appeals Should be submitted to: Blue Medicare Advantage HMO P.O. Box 4288 Scranton, PA 18505

14 Guidelines Overview Medicare edits and coding guidelines should be followed for Blue Medicare Advantage The claim should include the member s ID as it appears on their ID card, including the 3 letter alpha prefix ZGJ

15 Quick Reference Guide For the most up to date Quick Reference Guide refer to our Blue Medicare Advantage HMO website.

16 Provider Finder Directory Go to

17 Cont. Provider Finder Directory

18 Preferred Network Pharmacies * Over the counter purchase allowance may not be available in all plans. This is not mail order card. I Other pharmacies are available in our network.

19 All information presented will be available on the BlueCross BlueShield of Texas website: Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,