HOST CLAIM VOLUMES 2009

Transcription

1 1 CLAIMS Claims

2 HOST CLAIM VOLUMES

3 Mountain State Host/Par Claims 3

4 Medical Policy and Pre-Certification/Pre-Auth Router 4

5 Medical Policy and Pre-certification/ Pre-Authorization Router Effective October 1, 2010, providers will have access to medical policies and general pre-cert/pre-auth requirements of the Home Plan Provider will enter alpha prefix in a designated area(s) on the local Plan s Web site Provider will be routed to the Home Plan s medical policy and/or pre-cert requirements Providers must have access without logging in on the Home Plan s Web site Once medical policy and/or pre-cert requirements are viewed, provider will be re-connected to local Plan s Web site 5

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9 MEDICAL POLICY 9

10 Medical Policy Screens 10

11 Out of Area Member Medical Policy 11

12 Out of Area Member Medical Policy Router Page 12

13 DEFAULT CLAIMS RESOLUTION 13

14 Effective October 20, 2010 Default Claims 60 days from the timeframe the partner receives the claim if not processed it will be priced at the Host Plan s Allowance and processed for payment. Payment is based on 100% of contracted fee schedule allowance. This is an exception to standard claim processing and is not an overpayment. The provider is to keep any money collected from the member during the usual business process. A message code will appear on the provider remittance/ EOB. Based on policy this payment constitutes payment in full. Communication in the form of a letter will also be sent. 14

15 Business Drivers Reduce the number of aged claims and eliminate severely aged claims. Improve provider satisfaction by addressing a major cause of dissatisfaction. Incentive Partner Plans to resolve claims voluntarily before they reach 60 days. 15

16 MEDICARE ADVANTAGE 16

17 Medicare Advantage Provider Billing Reminder How do I identify a Medicare Advantage member? Medicare Advantage members have distinctive product logos on their medical ID card to help you recognize them. All logos have Medicare Advantage in the design. 17

18 What is Medicare Advantage? Medicare Advantage (MA) is a government program under which Medicare beneficiaries can opt-out out of original Medicare and enroll with a private carrier. Medicare beneficiaries opt-out out of traditional Medicare and elect benefits through private carriers, including Blue Plans. Centers for Medicare and Medicaid Services (CMS) allows private plans to offer eight different Medicare Advantage products. 18

19 Medicare Advantage Submission Requirements Electronic Claims must be submitted with NAIC Code of This is necessary to accommodate network sharing of Medicare Advantage PPO Networks. Paper p Claims must be submitted to: Mountain State Blue Cross Blue Shield 20 th & Chapline Street P.O. Box 7004 Wheeling, WV

20 Medicare Advantage Market Product Enrollment The MA Market has 11.1 million members as of Sept and increasing by 11% annually 12,000,000 October 2007 to May ,000,000 8,000,000 6,000, ,072 1,615, , , ,188 1,848, , , , , ,193,889 2,076, , , , , ,539 2,243, , , , ,050 2,328,938 2,347, , , , ,113 4,000,000 2,000,000 5,615,424 6,038,407 6,297,113 6,390,563 6,565,161 6,789,027 6,829,740 - October '07 January '08 April '08 July '08 January '09 April '09 May '09 20 HMO/HMOPOS Regional PPO Local PPO PFFS Other

21 Inter-Plan Medicare Advantage Product Enrollment In 2009, Blue Plans offers Medicare Advantage products in 31 states and enrolled 1.86 million members in MA Plans as of Sept Members HMO/POS 898, ,611 Local PPO 270, ,332 Regional PPO 66,460 83,988 PFFS 312, ,832 Cost 46,974 39,909 Total 1,593,832 1,857,672 All out-of-area Blue Medicare Advantage claims are sent through Inter-Plan systems 21

22 COORDINATION OF BENEFITS QUESTIONNAIRE 22

23 Coordination of Benefits Questionnaire Member COB questionnaires are available on Mountain State Blue Cross Blue Shield web-sites sites. The questionnaires can be used for MSBCBS members as well as BlueCard members. Under forms OPL/COB Questionnaires Give a copy to the patient during their visit Mail back to Mountain State Blue Cross and Blue Shield 23

24 REAL TIME CLAIM MEMBER LIABILITY 24

25 Member Liability Estimation for Mountain State Members MLE is an estimation of member cost sharing at a specific time. This estimation will be used by providers to understand what members may owe for services. 25

26 Real Time Estimator 26

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28 Member Liability Estimation For BlueCard Claims Deferred implementation until December 31, 2014 or when Healthcare Reform requires implementation, whichever is earlier. The value and importance of implementing Real Time Claims is recognized and the Association continues to support implementation on a voluntary basis. 28

29 ITS 11.1 RT/MLE Plans Implementing as Home Highmark NEPA West Virginia Alabama a Arkansas Florida Premera South Carolina HCSC (IL & TX pilot) Tennessee Mississippi 29

30 Medicare CrossOver Claims 30

31 Medicare claims with secondary coverage will be automatically crossed over and secondary claims do not need to be submitted. Providers receive notice on their MEOB that the claim has crossed over. Eligibility ibilit can be verified by submitting a HIPAA 270 electronic transaction, reviewing Navinet or by calling. Claim status t can be verified by submitting a HIPAA 276 electronic transaction, reviewing Navinet or by calling. 31

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33 2011 Benefit Changes

34 Presentation Topics Changes Impacting Medicare Advantage Eliminating Private Fee for Service 2011 FreedomBlue PPO benefit changes New Product FreedomBlue HD Important Dates

35 New CMS Bid Requirements Impact All Medicare Advantage Plans Requirement Establish maximum out-ofpocket limits, both voluntary and mandatory. Creates monetary thresholds to differentiate plans. Out-ofpocket costs between plans within a contract must vary by $20 based only on benefits. Holds employer groups to the same cost sharing and maximum out of pocket limits as direct pay plans. Encourages all plans to cover preventive screenings. Implication Moves closer to standardized Medicare Advantage products. Clearly defines the parameters for product differentiation. Applies some direct pay provisions to employer group plans. CMS mandated documents will identify those plans that do not cover preventive screenings.

36 The Health Care Reform Legislation included several changes to Part D coverage. Some take effect this year. Phases in of elimination of Part D coverage gap (2010) Medicare beneficiaries who reached the coverage gap during 2010 will receive a $250 rebate check from the federal government. Additional discounts on brand-name and generic drugs will be phased in to completely close the "doughnut hole" by Phases-in of federal subsidies for brand-name prescriptions in the Medicare Part D coverage gap (2013) In 2011 Medicare beneficiaries who reach the coverage gap will receive a 50 percent discount from manufacturers that participate in the Centers for Medicare & Medicaid Services discount program. Medicare beneficiaries will also receive a 7 percent discount on generic drugs in the coverage gap if their insurer does not cover generic drugs in the gap.

37 Eliminating Private Fee for Service The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) eliminated nonnetwork private fee for service plans in most areas effective January Private fee for service plans must be network based in areas where two or more network based products are available. FreedomBlue PFFS will not be available after January 1. Members will receive information about other coverage options in late September. FreedomBlue PFFS employer group members will be automatically transitioned to FreedomBlue PPO coverage.

38 Limited benefit changes for 2011 FreedomBlue made minimal benefit changes beyond those mandated by CMS. CMS mandated changes included: 100% coverage for preventive services; $3,400 in-network network out-of-pocket maximum; and $5,100 catastrophic out-of-pocket maximum FreedomBlue PPO Benefit Changes Value Standard Deluxe No service level maximums for inpatient hospital, skilled nursing facility or DME. Increased skilled nursing facility days from to Same changes as Value and Standard Additional Changes: Added cost sharing to labs and imaging. g Added podiatry and chiropractor visits

39 FreedomBlue PPO HD New for 2011 $0 premium with $1,000 deductible for Region 1 and Region 2 Zero premium with a $1,000 deductible. d Preventive care covered at 100 percent. Doctor s office visits do not apply to the deductible and are covered after a copayment. Basic prescription drug coverage is included. 5 percent coinsurance on some services until the member reaches the in- network out-of-pocket of maximum or the catastrophic maximum. Service Preventive care Physician office visits Inpatient Hospital Prescription Drug Dental Hearing Vision Coverage Level Covered at 100 percent $15 for PCP and $30 for Specialists 5 percent coinsurance after $1,000 deductible up to $1,000 out-of-pocket maximum. No gap coverage. Routine dental and denture coverage. $500 hearing aid allowance and routine exam. Routine vision exam, eyewear allowance or frames and lenses from Davis Vision.

40 Important Dates and Events Health Care Reform Legislation made several changes to the time periods associated with Medicare Advantage enrollment. June 7, Local MA Plan Bids and Benefits Submitted to CMS September 2010 Tentative ti CMS Approval of 2010 Local MA Plan Bids and Benefits October 1, Plan Marketing Activity Begins November 15, Annual Election Period Fall Enrollment Begins New time periods for 2011 Elimination of MA Open Enrollment Period (January 1 March 31) Implementation of MA Disenrollment-only Period (January 1 February 15) New Annual Enrollment Period (November 15 December 31 to October 15 December 7) December 31, Annual Election Period Ends

41 Questions? 41