Forms & Publications: Manuals, Bulletins, Quick Points, Provider Press. Administrative Updates: Forms for Demographic Changes

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1 MMGMA DAY WITH THE PAYERS May 19, 2016 Janet Benton, Director Provider Relations Kate Mikonowicz, Network Management Consultant, Pr. Shannon Hoskin, Network Management Consultant, Sr. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Associa,on. AGENDA BCBS Provider Website Overview and Updates MMGMA Questions: Billing Credentialing Education ICD-10 Communication PCP and VFC Incentive Program Discussion/Questions WEBSITE OVERVIEW Website: providers.bluecrossmn.com Forms & Publications: Manuals, Bulletins, Quick Points, Provider Press Administrative Updates: Forms for Demographic Changes Education Center: Seminar Schedule, Commercial Network Guide, Medicare Guide Medical Policy and Pre-Certification/ Authorization Router Operating System Transition All related Bulletins and QuickPoints are here in one place Medical Policy (local) link also includes Prior Authorization Information Reimbursement Policies 3 1

2 OPERATING SYSTEM TRANSITION Click on a topic to learn more and to see the Bulletins and Quick Points that have been published on each topic. 4 OPERATING SYSTEM TRANSITION Groups that have migrated: Small Group plans began migrating 11/1/15 Individual plans migrated 1/1/16 Blue Cross Employee Group migrated 1/1/16 FEP Migrated on 5/1/16 Member IDs will continue to begin with an R Large Group plans will begin migrating on 8/1/16 as the groups renew 5 MEDICAL POLICY WEBSITE UPDATES New landing page for Medical Policy information 6 2

3 MEDICAL POLICY WEBSITE UPDATES Click Medical and Behavioral Health Policies to review policies Click Utilization Management for information and forms related to Prior Authorizations/Pre-Certifications 7 MEDICAL POLICY WEBSITE UPDATES Select the appropriate Commercial Medical Policy set based on the whether the member has migrated to our new operating system Links to Medicare, DHS and FEP Medical Policy Information are listed Link to Upcoming Medical Policy Notifications 8 MEDICAL POLICY WEBSITE UPDATES Search by Keyword, Policy Number, Procedure Code, or Section Tip: Be sure to only search one Procedure code or Keyword at a time. 9 3

4 BILLING Can providers bill patients a no-show fee for missed appointments? PPPM, Chapter 2, Page 3, Responsibilities of Participating Providers Providers cannot bill Subscribers for missed scheduled appointments, except for missing a scheduled behavioral health appointment, provided the provider has notified the Subscriber in writing in advance that this is the provider's policy. Please note that PMAP, MinnesotaCare, and Medicare Subscribers may not be billed for missed appointments. Can the patient be held accountable for timely filing claims denials due to patient not providing correct insurance information? PPPM, Chapter 8, Pages 26-27, Timely Filing No, providers must still submit a claim and may appeal denial with supporting documentation. Please refer to PPPM for more detailed information. 10 BILLING Can providers withhold non-emergent care from patients with an outstanding account balance? Blue Plus Provider Manual, Chapter 2, Page 2, Clinic Requested Discontinuation of Subscriber Health Services The Manual outlines the process providers should follow for Subscribers with outstanding liability amounts. Providers should first try and work with the Subscriber to resolve the issue. If no resolution is reached, providers may disenroll the Subscriber by following the process outlined in the Manual. What recourse does a clinic have when the health plan pays less than the clinic s cost of the drug? Providers should submit detailed information via an appeal, including the provider s invoice for the drug, for review of allowance. 11 BILLING For services that your health plan will not cover, do you require clinics to use a specific form to notify patients prior to these services being rendered? PPPM, Chapter 4, Page 29, Sample Waivers Sample waiver forms for Commercial and MHCP are available on BCBS provider website under Forms and Publications, Forms-Clinical Operations. For Platinum Blue, please refer to Provider Bulletin P27-15, published July,

5 PROVIDER CREDENTIALING PROCESS & TIMELINE The BCBS Credentialing Manual can be found in the Forms and Publications section on the Blue Cross website: 13 PROVIDER CREDENTIALING PROCESS & TIMELINE A quick list of facility types and practitioner specialty types that require credentialing is available under the Reviewed Specialties dropdown. Please review the Credentialing Policy Manual found here. 14 PROVIDER CREDENTIALING PROCESS & TIMELINE Does your organization have a committee approval process and what happens if the date is missed? Clean applications, which are the majority, are approved by a Medical Director on a weekly basis and do not require committee approval. Only applications with issues go to the Credentialing Committee, which meets the 2 nd Wednesday of every month. Preferred method for submitting credentialing applications, both initial and re-credentialing, is through ApplySmart at BCBS works to complete all provider credentialing within 90 days. Providers become effective the latter of credentialing approval date or requested effective date. BCBS policy is to not retroactively credential providers. 15 5

6 EDUCATION CENTER: SEMINARS 16 EDUCATION CENTER: 2016 COMMERCIAL NETWORK GUIDE Two new networks available in 2016 Consumer Value Network no longer offered on the exchange 17 EDUCATION CENTER: GUIDE TO MEDICARE PRODUCTS 18 6

7 EDUCATION CENTER: GUIDE TO MEDICARE PRODUCTS 19 MEMBER EDUCATION Providers can utilize to verify member eligibility, benefits and network requirements Through Availity, providers can determine member deductibles and if out of pocket maximums have been satisfied Providers can call BCBS provider services for additional information ( ) Members can access benefit information via the BCBS App available for IPhone and Android users 20 ICD-10 How does your organization plan to use ICD-10 information going forward? BCBS will utilize ICD-10 codes in the same way we utilized ICD-9 codes in the past. 21 7

8 COMMUNICATION How do clinics access a contract representative within our organization to discuss terms and renewals? Providers should contact BCBS provider service if they have questions about their contract renewal documents. If a clinic disagrees with the outcome of a claim appeal, what recourse do they have? If the claim is for over $500 and provider has additional supporting information, a second level appeal can be submitted. Providers may also submit an appeal on behalf of the member with the member s signature for approval. How can providers reach a live body within your organization? Providers can call BCBS provider services. 22 COMMUNICATION What tips can we offer to improve interactions with Blue Cross? What would we like you to know? BCBS and the MMGMA Payer Relations Committee meet on a quarterly basis. Please bring issues to your Payer Relations Committee for inclusion on an upcoming meeting agenda. Providers should review BCBS provider communications on a regular basis. Provider Bulletins are mailed and posted on the BCBS provider website; Provider Quick Points and the quarterly Provider Press are only posted on the BCBS provider website. Other good resources include the Provider Policy and Procedure Manual and the Reimbursement Policies. 23 PCP & VFC INCENTIVE PROGRAM How were the overpayments calculated? The settlement amount was the difference between the 2013 and 2014 adjusted Medicare rates and what BCBS paid out (i.e., DHS Rate) This was a pass through from DHS DHS determines provider eligibility 24 8

9 PCP & VFC INCENTIVE PROGRAM Who should providers contact with questions? Providers can reach out to the BCBS contact listed in the settlement letters. Providers should also refer to the PCP & VFC Incentive Program page on the MDH website for more information. 25 THANK YOU. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Associa,on. 9