Hospital Quick Reference Guide

Transcription

1 Hospital Quick Reference Guide Rev 11/2005

2 Table of Contents Introduction... 1 Provider Access (our Web site Eligibility & Benefits Verification And Claims Status Inquiries Preauthorization/Referrals Referrals Claims Submission Requests for Clinical Information Fee Schedule Requests Claims Processing...23 Continuity of Care...24 Claims Payments...25 Claims Recovery/Refunds EDI Services...29 In the event of a conflict between this Physician Office Manual and the Physician Agreement or the Physician Office Manual and the Membership Agreement the Physician Agreement or the Membership Agreement respectively will control. Rev 11/2005

3 Preferred Drug List...30 Mail Order Prescription Program...31 BlueCard Program...32 Provider Directory...33 Rev 11/2005

4 Introduction Blue Cross Blue Shield of Georgia (BCBSGa) Blue Cross Blue Shield Healthcare Plan of Georgia (BCBSHP) This guide is intended to serve as a quick reference tool for the broad range of health plans offered by Blue Cross Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia. The information contained in this Physician Quick Reference Guide refers to the following health care plans and their underwriters: Blue Cross Blue Shield of Georgia (BCBSGa) BlueChoice PPO Traditional Health Plan (Indemnity) FlexPlus 65Plus Hospital/Surgical Blue Cross Blue Shield Healthcare Plan of Georgia (BCBSHP) BlueChoice Healthcare Plan (HMO) BlueChoice Option (POS) Blue Direct This Quick Reference Guide also applies, as indicated, to self-funded plans administered by Blue Cross Blue Shield of Georgia, for example, AT&T, West Point Stevens, etc. While the guide contains the most current data available as of the date of publication, it is not meant to provide complete information about all aspects of Blue Cross and Blue Shield health plans. Your local Senior Network Specialist can provide more specific details about how our health plans work. 1 Rev 11/2005

5 Provider Access Participating BCBSGa/BCBSHP physicians and their staffs have fast, easy access to information about patients and claims 24 hours a day, 7 days a week. Simply log on to and click on Provider Access. Some secure areas require a password that can be applied for online. Physicians will receive their password in the mail within 7 to 14 days. Provider Access is the total information source for: Member eligibility and benefits Co-pay, deductible and co-insurance amounts PCP Type of health plan Routine benefit descriptions Accumulations for deductibles and out-of-pocket maximums Claim status Claim ID number Date of service Billed and paid amounts Remits CPT code and contract type Immediate print-out of a specific remit Referrals Online referrals are available by providing the member s information and the name of the specialist to whom the patient will be referred. BlueExchange BlueExchange is our online service where physician practices may conduct transactions related to patients they have treated who are enrolled in a Blue Cross and Blue Shield plan outside of Georgia. Available online transactions include: Eligibility/benefits inquiry (270/271) Claim status inquiry (276/277) 2 Rev 11/2005

6 To request these transactions, simply go to and click on Provider Access, then select On-line Transactions. The member prefix of the plan located outside of Georgia is required. Each of the request screens for these transactions requires a member prefix. Transaction requests are sent to the home plan the plan that enrolled the member. Some home plans respond immediately, in real time. In this case, the response will be displayed on the screen. The process may take up to 50 seconds. In general, benefits, referral and pre-authorization inquiries are handled in real time. Some home plans do not have real time response capabilities and choose to process their transactions in batch mode. In this case, the home plan will send a response that will be displayed on our secure Message Center. This process may take up to 24 hours. However, physicians will receive a message indicating that their request has been received. Other valuable resources Provider Access offers the latest information about our medical management activities, treatment protocols, credentialing standards and future plans. Provider Access also maintains current information about disease management programs, HEDIS, physician profiling, our Complementary Medicine Program and physician rights and responsibilities. Through Provider Access, providers have the ability to offer feedback to BCBSHP and make suggestions about topics they would like to see included. Provider Access complements Provider Communicator, our newsletter that contains updates about policy and procedure changes, best practices, legislative and regulatory initiatives and new therapy advisories. 3 Rev 11/2005

7 Eligibility & Benefits Verification and Claims Status Inquiries The following is a list of steps to take to verify eligibility and benefits of BCBSGa/ BCBSHP members. Capture the information listed on the member s ID card for billing purposes. Also, copy the front and back of the member s ID card and file in the member s chart for future reference. Verify eligibility and benefits before rendering services via our web site or by calling the appropriate telephone number based on the member s benefit plan. The telephone number can be found on the front of the member s ID card. For the BCBSGa/BCBSHP plans listed below, verification of a member s eligibility and benefits can be conducted via the internet at Once you have obtained the required logon ID and password, you may verify the member s eligibility and basic benefit information via the internet. Instructions for requesting the required logon ID and password are found on the Provider Corner of the web site. BlueChoice Healthcare Plan (HMO) BlueChoice Option (POS) Blue Direct BlueChoice PPO Traditional Health Plan (Indemnity) Hospital/Surgical Select self-funded groups Verification of a member s eligibility and benefits can also be conducted via the telephone Voice Response Unit (VRU) at hours, 7 days per week. For all other plans, verification of a member s eligibility and benefits can be made directly to a customer service associate by telephone. Please refer to the 4 Rev 11/2005

8 front of the member s ID card for the appropriate customer service telephone number. To check on claims submitted to BCBSGa/BCBSHP: A claim status may be verified via the internet at Please access the Claim Status through the Provider Corner of our web site. Please wait at least thirty (30) calendar days after submitting a claim before checking the claim status via our web site or calling BCBSGa/BCBSHP to verify the status of the claim. This will allow sufficient time for complete processing of the claim. If the claim is submitted electronically, verify that the claim was not rejected electronically (see EDI Services on page ) and if rejected, and the claim status is not available through our web site, that it was corrected and resubmitted. The status of the claim may also be obtained by calling the appropriate BCBSGa/BCBSHP telephone number based on the member s benefit plan. The following information is required to verify a member s eligibility and benefits and/or to inquire on the status of a submitted claim: Type of plan (ie: BlueChoice Healthcare Plan, FEP, NASCO, etc.) Member s name Member s ID number including the alpha prefix and numeric suffix Member s date of birth (MM/DD/YYYY) Date of service (required for claim status inquiries only) (MM/DD/YYYY) Charges submitted (required for claims status inquiries only) 5 Rev 11/2005

9 Not sure who to call? The following phone numbers will help you determine who to call to verify a member s eligibility and benefits and/or to inquire on the status of a submitted claim: Plan/Service Phone Number Hours of Operation Provider Access Help Desk/Customer Support hour a day/7 days a week ( (8:00 AM 6:00 PM) BCBSGA/BCBSHP VRU :00 AM 7:00 PM BlueCard/ITS* Eligibility Claim Status :00 AM 10:00 PM 7:00 AM 9:00 PM Option #4 Federal Employee Program (FEP) :30 AM 5:30 PM State Health Benefit Plan Indemnity & PPO Eligibility, Benefits and Claim Status Inquiry :00 AM 6:00 PM (Mon-Fri) 8:00 AM 6:00 PM (Mon-Fri) State Health Benefit Plan (HMO) :30 AM 7:00 PM NASCO Atlanta Area :00 AM 4:30 PM 9:00 AM 4:30 PM AT&T :30 AM 5:30 PM West Pointe Stevens :00 AM 4:30 PM Mental health and substance abuse services hours a day/7 days a week Fax: Georgia Bankers Association** :00 AM 4:00 PM Wal-Mart VRU** :00 AM 7:00 PM University System of Georgia Health Benefit :00 AM 7:00 PM Plan (USG Health Benefit Plan) Vision :00 AM 5:00 PM Utilization Management Pre-Certification Fax or :30 AM 4:30 PM 6 Rev 11/2005

10 Plan/Service Phone Number Hours of Operation HMO BlueUSA program hours a day/7 days a week EDI Services For Vendor Supported Sites For EDI Product Customers (Blue Connect, Online DDE and RealTime Transactions 270/271; ; 278)) The following addresses and phone numbers are for Service Area Contacts Region Office Address Phone Number HMO/POS Service Area (Counties) Albany 2407 Westgate Drive Albany, GA (229) Baker, Ben Hill, Berrien, Brooks, Clay, Colquitt, Cook, Crisp, Dougherty, Early, Echols, Grady, Irwin, Lanier, Lee, Lowndes, Miller, Mitchell, Quitman, Randolph, Seminole, Sumter, Terrell, Thomas, Tift, Turner, Worth Athens 400 Hawthorne Ln Athens, GA (706) Barrow, Clarke, Greene, Jackson, Oconee, Oglethorpe, Morgan Atlanta 3350 Peachtree Rd, NE Atlanta, GA (404) Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Heard, Henry, Newton, Paulding, Rockdale, Spalding, Walton Augusta 2743 Perimeter Pkwy Bldg 100, Ste 375 Augusta, GA (706) Aiken, Burke, Columbia, Emanuel, Glascock, Hancock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro, Warren, Washington, Wilkes Columbus 1200 Brookstone Centre Ste 105 Columbus, GA (706) Chattahoochee, Dooly, Harris, Lamar, Macon, Marion, Meriwether, Muscogee, Pike, Schley, Stewart, Talbot, Taylor, Troup, Upson, Webster Gainesville 332 Washington St, NW Ste 110 (770) Banks, Dawson, Habersham, Hall, Lumpkin, White Gainesville, GA Macon 3200 Riverside Dr Bldg B, Ste 100 Macon, GA (478) Baldwin, Bibb, Bleckley, Crawford, Dodge, Houston, Johnson, Jones, Monroe, Montgomery, Peach, Pulaski, Treutlen, Twiggs, Wheeler, Wilkinson Rome 105 Laurel Creek Rd Calhoun, GA (706) ext 18 Bartow, Catoosa, Chattooga, Dade, Floyd, Gilmer, Gordon, Murray, Pickens, Polk, Walker Savannah 12 Chatham Center South, Suite B Savannah, GA (912) Bryan, Bulloch, Chatham, Effingham, Liberty 7 Rev 11/2005

11 Preauthorization The provider is responsible for verification of member eligibility and covered benefits. Except when an emergency, failure to obtain authorization prior to rendering designated services (listed below and as required in the Benefit Plan) will result in a denial of reimbursement. There are now some outpatient diagnostic procedures which can be preauthorized through our web site ( click on Provider Access and go to on-line transactions. The procedures that are available on the web site are indicated in the table below. A minimum timeframe of three (3) business days is required to complete a thorough clinical analysis prior to the member s proposed elective procedure date. An authorization number will be returned to your office within three (3) business days of receipt of complete clinical information. The format of the number can be alpha numeric or plain numeric. Contracted facilities must notify BCBSHP within twenty-four (24) hours or the next business day from the time of all inpatient admissions. 8 Rev 11/2005

12 PRE-CERTIFICATION REQUIREMENTS FOR BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC. PARTICIPATING PROVIDER (INDEMNITY) AND PREFERRED PROVIDER ORGANIZATION (PPO) AND BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC. BLUECHOICE HEALTHCARE PLAN (HMO), BLUECHOICE OPTION (POS), BLUE DIRECT (HMO/POS) EFFECTIVE DATE: November 1, 2005 Eligibility/benefits can be verified by accessing the BCBSGa web site or by calling customer care (Mon Fri, 7 am 7 pm ET) Eligibility and Benefits Service pre-certification is based on member s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility/covered benefits. Except when an emergency, failure to obtain precertification prior to rendering the designated services listed below will result in denial of reimbursement. All Imaging Procedures for All Lines of Business (except in an emergency or for inpatient admissions) The following procedures must be pre-certified through National Imaging Associates (NIA) (Mon Fri, 8 am 8 pm ET) once eligibility and benefits have been verified with BCBSGa/BCSHP CT Scans (Except guidance related, codes 72126, Nuclear Cardiology and 72132) PET Scans MRIs CTAs and MRAs HMO, POS and Blue Direct HMO Institutional Admissions Requiring Pre-certification Acute Inpatient (Including Transplants) All out-of-network/out-of-area non-emergency Sub-acute Inpatient (Skilled Nursing and Long Term services Care) All mental health and substance abuse services Inpatient Rehabilitation Call Outpatient Services Requiring Pre-certification Arthroscopy shoulder/knee Orthognathic/TMJ Biofeedback Reconstructive Surgery EMG/Nerve Conduction Studies Sleep Studies Epidural/Facet Injections for Pain Management UPPP Gastric Obesity Surgery Transplant Evaluations Call or Home Health Skilled Nursing Fax Hysterectomy (Age < 35) All mental health and substance abuse services Call Service Coverage POS Services listed above require pre-certification and will be denied if rendered without the appropriate pre-certification regardless of whether rendered in or out-of-network. Except for Blue Direct specialists performing services that no longer require pre-certification must have a referral for in-network benefit payment. If there is no referral or the member selfreferred, the out-of-network benefit level will be paid. HMO Services listed above require pre-certification and will be denied if rendered without the appropriate pre-certification regardless of whether rendered in or out-of-network. HMO members do not have benefits for non-emergency services rendered outside of the network without obtaining an authorization. Indemnity (PAR) and Preferred Provider Organization (PPO) Institutional Admissions Requiring Pre-certification Inpatient Rehabilitation Acute Inpatient (Including Transplants) All mental health and substance abuse services Sub-acute Inpatient (Skilled Nursing and Long Term Call Care) All facilities must notify us within 24 hours or the next business day after admission. 9 Rev 11/2005

13 Outpatient Services Requiring Pre-certification Arthroscopy shoulder/knee Orthognathic/TMJ Biofeedback Reconstructive Surgery Gastric Obesity Surgery Sleep Studies Home Health Skilled Nursing UPPP Hysterectomy (Age < 35) Transplant Evaluations Call or Fax Effective January 1, 2006 the Following Procedures Will Require Pre-certification EMG/Nerve Conduction Studies Epidural/Facet Injections for Pain Management Pre-certification/ Pre-notification Process for BSBSGa Submit all required clinical information 15 calendar days before the proposed procedure when possible. A minimum time frame of three business days is required to complete a thorough clinical analysis. A pre-certification number will be provided to you once all clinical information has been received and reviewed. Institutional Admissions All facilities must notify us within 24 hours or the next business day (whichever is earlier) after admission. Pre-certification requests can be submitted as follows: Routine Requests Fax (PAR/PPO) or (HMO/POS) Phone Emergent / Urgent Phone National Imaging Associates (for CT, CTA, MRI, MRA, PET Scans and Nuclear Cardiology) Mental health and substance abuse services Fax Behavioral Health Services Pre-service and concurrent review for Behavioral Health Services activities are conducted by licensed professionals using BCBSHP Behavioral Health Criteria for Medical Necessity. The criteria set can be found in the Provider section of our web site 10 Rev 11/2005

14 Referrals: BlueChoice PPO Referrals to specialists for PPO members do not require prior authorization by BCBSGa or the member s primary care physician. However, as stipulated in the Preferred Physician/Provider Agreement, all referrals should be made to other PPO physicians and providers. Referrals to other PPO physicians and providers ensures that members receive the maximum benefit under their health plan. BlueChoice HMO/POS When preauthorizing referrals to a Specialty Care Provider, the PCP should follow these guidelines: How to submit the Request/Notification Web Site Provider Access... Fax... (800) Phone... (800) Referral Numbers A referral number is not necessary and will not be supplied. Referrals are notification only. When to submit the request Submit all notifications of referrals prior to member s receiving services from specialists. Retrospective requests for non-emergent specialist referrals will result in delays and/or denials in claim payment. Selecting the Provider Select a network provider consistent with the specialty care needs of the member from the specialty care provider list. Member preference If the member has a preference, the PCP should consider this preference when selecting a Specialty Care Provider. Contacting the UM Department If you need assistance or have questions, contact BCBSHP s UM Department at (800) or (404) from 8 AM to 5 PM weekdays. The UM Department, in conjunction with the PCP, will coordinate the request for a specialist referral. 11 Rev 11/2005

15 Required Information The following information is requested to process referrals: Member name Member identification number Number of visits and time frame for referral Member diagnosis Practitioner Name / Specialty Extending Referrals PCP - Should the PCP wish to extend an existing referral or request additional specialty care services for the member, the PCP should notify the UM Department. Specialist - Should a specialist request a referral or an extension of a referral, the specialist should notify the UM Department. Payment for Services Payment for services is subject to the member s Membership Agreement and eligibility on the date of service. Should the member not be eligible on the date of service, payment for the services becomes the responsibility of the member. Requests may be made via our web site ( telephone, fax or electronic transmission. Referrals are notification only and a referral number is not necessary and will not be supplied. Blue Direct Blue Direct members are required to select a PCP and are encouraged to maintain that relationship. However, Blue Direct members have the option of accessing specialty care directly through a BlueChoice HMO Specialty Care Physician without obtaining a prior referral from their PCP. Blue Direct members have a specifically labeled member identification card designating them as Open Access participants. The card will include co-payment amounts along with the standard benefit information included on all member ID cards. 12 Rev 11/2005

16 Claims Submission BCBSHP HMO, POS and Blue Direct Encounter Reporting All services provided to Blue Corss Blue Shield Healthcare Plan of Georgia (BCBSHP) members must be reported in the standard HIPAA compliant claim format using HIPAA-compliant code sets on the CMS-1500 claim form or the equivalent, within the filing standards timeframe, and with applicable charges noted. This is necessary for reporting of utilization data and HEDIS purposes. The claim system will identify CPT codes eligible for fee-for-service payment and will approve those services when appropriate. Claims and encounter forms for BCBSHP members may be mailed to: BlueChoice Healthcare Plan, BlueChoice Option and Blue Direct C/o Blue Cross Blue Shield of Georgia P. O. Box 9907 Columbus, GA Claims and encounters can also be filed electronically. For further information about electronic filing, please contact EDI Services at Procedures for electronic claims filing are also available on our web site, with the Electronic Transaction Manual under EDI Services. BCBSGa PPO Filing Claims BCBSGa PPO Physicians are required to accept the BlueChoice PPO member s identification card in lieu of payment up-front and to file claims for members. All services provided to BlueChoice PPO members must be filed using the standard HIPAA compliant claim format and HIPAA complaint code sets on the MCS-1500 claim form or the equivalent, within the filing standards timeframe, and with applicable charges noted. 13 Rev 11/2005

17 The charges for services rendered to BlueChoice PPO members and guest members should be at the same rate as for all other patients and claims should be submitted to BCBSGa within the filing standards timeframe. Mail hardcopy claim forms to the address indicated on the PPO identification card. Claims can also be filed electronically. For further information about electronic filing, please contact EDI Services at Procedures for electronic claims filing are also available on our web site, with the Electronic Transaction Manual under EDI Services. The following information is required for submitting electronic and/or hard copy claims to BCBSGa/BCBSHP: Current ICD-9 diagnosis codes, HCPCS and CPT-4 procedure codes. (There should be only one procedure code per line and codes should be listed to the fifth digit. HCPCS and CPT-4 procedure codes should include modifiers where applicable.) Complete all fields and submit on standard pre-printed UB92 form. The following are examples of significant data elements: Valid bill types and revenue codes Diagnosis code(s) Hospital name and tax ID Dates of service (Admit and Discharge dates) Complete and accurate member and insurance information including: Alpha prefix and numeric suffix with member s ID number Correct spelling of the member s name Date of birth and sex of member Additional information for submitting claims to BCBSGa/BCBSHP: Include actual CPT-4 code only once for each claim line and V-codes for well care. Submit therapy charges with the number of units equal to the number of days these services were rendered and not the number of modalities per service. Check formatting and print quality of hard-copy claims before submission. Misaligned data elements and light print may prevent your claims from being processed. 14 Rev 11/2005

18 Include primary payment information with coordination of benefits (COB) claims submitted for secondary payment. Obtain required pre-authorizations. Use the prefix in front of the member ID number for all claims. Examples include: S State Health Benefit Plan members, R Federal Employee Program members and XKH BCBSHP members. Verify eligibility and benefit limits before rendering services. Rubber-stamp the type of claim (e.g., adjustment, corrected bill, tracer, etc.) on the face of hard-copy bills to ensure correct identification. Do not use red ink when stamping, because the scanning equipment may not be able to read this information. Corrected bills are those where a remittance advice has already been received by the provider. Check the back of the member s insurance card for the correct mailing address for hard-copy claim submissions. The following are common reasons for rejected claims (i.e., claims that cannot be processed): Outdated, incomplete, or non-specific ICD-9, Revenue Codes, HCPCS and/or CPT codes on the claim Incomplete data elements Invalid or incorrect contract information (i.e., member number) Member ineligible for BCBSGa/BCBSHP coverage Illegible hard-copy claims (Note: Rejected hard-copy claims will be mailed back to the sender along with a request for additional information that is necessary to process the claim.) The following are types of claims that should not be submitted electronically: Transplant services for SHBP and USG Health Benefit Plan Indemnity and PPO patients, other than kidney and cornea, must be filed with UNICARE. The address for UNICARE is listed below. 15 Rev 11/2005

19 The following are tips for resubmitting claims: Please verify that the claim has not been received by BCBSGa/BCBSHP and do not resubmit claims until at least thirty (30) calendar days have passed from the original date of submission. Resubmitted claims will be denied as duplicates when the original claim has already been received by BCBSGa/BCBSHP unless changes have been made and the new claim is identified as an adjusted/corrected claim. Corrected bills are those claims for which a remittance advice has already been received by the provider. Mailing Addresses for Submitting Hard Copy Claims: University System of Georgia BCBSGa/BCBSHP Health Benefit Plan Blue Cross Blue Shield of Georgia (USG Health Benefit Plan) PO Box 9907 University System of Georgia Columbus, GA PO Box 7728 Columbus, GA State Health Benefit Plan Indemnity/PPO Behavioral Health Services (for all non-rx claims, medical and behavioral claims) State Health Benefit Plan PO Box Atlanta, GA Federal Employee Program UNICARE (select transplant claims for SHBP Federal Employee Program and USG Health Benefit Plan) PO Box 7037 UNICARE Center for Expertise Columbus, GA PO Box Atlanta, GA NASCO Blue Cross Blue Shield of Georgia PO Box 4055 Atlanta, GA Rev 11/2005

20 Requests for Clinical Information On the following page is a standard cover sheet for submitting clinical information when filing an initial paper claim. Using this cover sheet will help ensure that documentation is attached to the right claim(s) and will expedite processing. You may also use this form when you know in advance that BCBSGa requires clinical information (such as an unlisted procedure code). If you have received a request for clinical information and if you have the claim number, you may also use this form to submit supporting documentation. VERY IMPORTANT NOTE: If BCBSGa has requested clinical information, please follow the instructions in the request/letter and attach a copy of the request/letter as the cover sheet. The bar coding helps to expedite processing! YOU CAN FAX (IF LESS THAN 25 PAGES) OR MAIL YOUR COVER SHEET AND INFORMATION TO: Blue Cross Blue Shield of Georgia 2357 Warm Springs Road Columbus, GA Fax: Clinical Submission Categories The following is a list of claims categories where we may routinely require submission of Clinical Information before or after payment of a claim: Claims involving pre-certification/prior authorization/pre-determination (or some other form of utilization review including but not limited to: Claims pending for lack of precertification or prior authorization Claims involving Medical Necessity or Experimental/ Investigative determinations Claims for pharmaceuticals requiring prior authorization. Claims involving certain modifiers, including but not limited to Modifier 22. Claims involving unlisted codes 17 Rev 11/2005

21 Claims for which we cannot determine from the face of the claim whether it involves a Covered Service thus the benefit determination can t be made without reviewing medical records (including but not limited to pre-existing condition issues, emergency service-prudent layperson reviews, specific benefit exclusions). Claims that we have reason to believe involve inappropriate (including fraudulent) billing Claims that are the subject of an audit (internal or external) including high dollar claims. Claims for individuals involved in case management or disease management. Claims that have been appealed (or that are otherwise the subject of a dispute, including claims being mediated, arbitrated, or litigated) Other situations in which clinical information might routinely be requested: Requests relating to underwriting (including but not limited to member or physician misrepresentation/fraud reviews and stop loss coverage issues); Accreditation activities; Quality improvement/assurance activities; Credentialing; Coordination of benefits; and Recovery/subrogation. Examples provided in each category are for illustrative purposes only and are not meant to represent an exhaustive list within the category. 18 Rev 11/2005

22 BLUE CROSS BLUE SHIELD OF GEORGIA/ BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA Supporting Documentation Standard Cover Sheet Original Claim Number: Claim Identification Information: Patient First Name: Patient Last Name: Patient Date of Birth: Date(s) of Service: Provider of Service: Tax ID#: Subscriber/Member ID# with prefix and suffix: Subscriber s First Name: Subscriber s Last Name: Provider Contact Person Name: Contact Phone Number: Comments (Optional): Identify the documentation that you have attached. Privacy Statement: This document contains Confidential Information. Any disclosure, copying or distribution is prohibited. If you have received this information in error, notify the sender and destroy all copies. 19 Rev 11/2005

23 Fee Schedule Request Procedure According to their contractual agreement, providers who are reimbursed on a feefor-service basis may request complete fee information showing applicable fee schedule amounts or request up to one hundred (100) CPT codes customarily and routinely used. These requests will be accepted twice per year. Use the Fee Schedule Request Form on the following page to submit requests for fee schedule amounts. The form is also available on our web site, Requests can be made by , fax or phone call. If submitting a request via , please use the online form available on our web site, under Forms and Links. After completing the form with the requested CPT codes, send this form as an attachment to the following addresses, based upon the location of the participating provider: IPSUNorth@bcbsga.com - Participating providers practicing in the Atlanta metro area and all areas north of Atlanta. IPSUSouth@bcbsga.com - Participating providers practicing in all areas south of Atlanta. If submitting a request via fax, fax the completed Fee Schedule Request Form to If submitting your request via phone call, please use the following phone numbers based upon the location of the participating provider: Atlanta area providers please call North Georgia providers please call South Georgia providers please call BCBSGa/BCBSHP will respond to your Fee Schedule Request within five (5) business days by , fax or return phone call, based upon the method chosen by the provider. 20 Rev 11/2005

24 FEE SCHEDULE REQUEST FORM Please send requests via , fax or phone call: - Participating providers practicing in the Atlanta metro area and all areas north of Atlanta. - Participating providers practicing in all areas south of Atlanta. Fax Please fax request form to Phone For all participating PCPs in the Atlanta metro area For all participating PCPs in North Georgia For all participating PCPs in South Georgia Please complete the following to submit your request and provide the necessary address or fax information needed to return the fee schedule request information: *Provider or Group Name: Contact Name: *Tax I.D.: * Address: *Street Address: *Fax Number: *Denotes that this is a required field 21 Rev 11/2005

25 Full Fee Schedule Specific CPT codes listed below BCBSGa/BCBSHP will respond to your Fee Schedule Request within five (5) business days by , fax or return phone call, based upon the method chosen by the provider. 22 Rev 11/2005

26 Claims Processing Payor System Edits: In addition to EDI edits, certain operating system edits may prevent the claim from automatically adjudicating. These suspended claims may require additional information to complete processing. It is important that the information requested be provided in a timely manner. Medical Review Process: For claims requiring medical review, providers will be notified of the required information to be submitted and where to mail or fax the information. To avoid denials, it is important that the requested information be submitted within the time period indicated on the letter of request. Medical Management/Appeals Process: Appeals are formal requests, either oral or written, to express dissatisfaction with a decision not to certify an admission, request an extension of a patient s stay, or other health care services or procedures. If the provider remains dissatisfied after receiving the initial decision, he or she may initiate a complaint by sending documentation, including a cover letter outlining the issue. If the complaint is 10 pages or fewer, the complaint can be faxed to For longer documents, the provider can mail to: BCBSGa Attn: Provider Appeals P.O. Box 9907 Columbus, GA Appeal of initial determination: Appeals can be initiated by the member, the physician, or the facility. Decisions are generally made within thirty (30) business days after receipt of necessary documentation. 23 Rev 11/2005

27 Continuity of Care Effective July 1, 2002, Senate Bill 476 applies to any contract extended, renewed, or newly executed after that date. Section 9, Article 3 (33-20A-60 and 33-20A-61) of the bill outlines the circumstances when the covered person may continue to receive care after the physician or BCBSHP terminates the physician s existing agreement. A member has the right to continue receiving health care services for 60 calendar days from the date of termination when: The member is receiving care for a chronic illness The member is receiving care for a terminal illness The member is in the hospital at the time of the physician s termination If the member is pregnant, she has the right to receive health care services connected with the pregnancy for the remainder of the pregnancy and for a six-week postdelivery period. The continuation provision for members does not apply if the physician s license has been suspended or revoked, or when BCBSHP determines that the physician poses a threat to health, safety, or welfare of the member. 24 Rev 11/2005

28 Claims Payments Check Schedules: Checks for BCBSGa/BCBSHP, FEP and University System of Georgia claims are issued according to the following schedule: Provider Tax ID Check Issued Checks Dated Monday Checks Dated Tuesday Checks Dated Wednesday Checks Dated Thursday Checks Dated Friday SHBP and NASCO checks for medical claims are issued on Fridays. Separate checks are issued for SHBP, NASCO, FEP, University System of Georgia, and BCBSGa/BCBSHP. Adjusted/corrected claim payments are issued daily or are included with the regular check if the payment date falls on the provider s issuance date. Remittance Advice Reconciliation: Remittance advices are sent to providers along with check payments. To ensure that remittance advice information is accurately and completely posted to members accounts, reconciliation should be performed for each payment. For questions concerning the remittance advice, please call the applicable customer service department based on the member s plan coverage. Charges denied as provider liability should be written-off to prevent an overstatement of the accounts receivable balance. Members may not be billed for the difference between the provider s charges and contracted amount. If you have questions concerning contractual issues, contact your local Senior Network Specialist. 25 Rev 11/2005

29 Claims Recovery/Refunds Overpayment Recovery Procedure Blue Cross Blue Shield Healthcare Plan of Georgia has instituted an automated deduction collection process in an effort to recover payments issued in error and when routine collection efforts have not been successful. Account is equal or greater than $5,000 for a Professional claim Account is equal or greater $10,000 for a Facility claim A phone call is made and a fax of the first notice is sent to the provider. Any questions or concerns are handled on this first contact. Arrangements are made for payment. Account is equal or greater $1,000 for Member-Paid claim Account is less than $5,000 for a Professional claim Account is less than $10,000 for a Facility claim The first and second notices are mailed as prescribed below and a final letter is sent certified mail. The first notice is mailed to the provider s business office asking for payment within 30 calendar days. If payment is not received before the 30 calendar day period ends, a second notice is mailed to the provider asking for payment within 30 calendar days. If the account remains open after a total of 60 calendar days has passed, auto-deduction will occur. Resulting remittance advices will report the item(s) deducted and will include the related contract numbers to assist the provider. Remittance remark code 06 identifies that all or part of the total claim payment will be reduced by an outstanding refund request. Remittance remark code 24 identifies the outstanding refund claim. Note: All procedures are evaluated periodically to determine Best Business Practices and to remain consistent with business standards. Please be assured every effort will be made to collect the refund without activating the automated deduction collection process. 26 Rev 11/2005

30 For questions concerning overpayment by the health plan, please call from 7:00 am 7:00 pm, Monday through Friday. For the State Health Benefit Plan (SHBP) call from 7:00 am 8:00 pm, Monday through Friday. To contact BCBSGa/BCBSHP regarding an overpayment, please use the addresses below: PAYMENTS: INQUIRIES/APPEALS: BCBSGa/BCBSHP BCBSGa/BCBSHP P. O. Box 4445 P. O. Box 7368 Atlanta, GA Columbus, GA Attn: Cash Receipts Attn: Refunds *Note: All requests for appeal that are received by BCBSGa/BCBSHP within thirty (30) days of receipt of a request for repayment of an overpayment will not require the provider to repay until the appeal has been resolved and a final decision has been reached. Providers may make refunds directly to BCBSHP when overpayments are made in error by BCBSHP. The Refund Memorandum (next page) should accompany all providerinitiated refunds. 27 Rev 11/2005

31 Refund Memorandum Mail to: Cash Receipts Department BCBSGa/BCBSHP P.O. Box 4445 Date: Atlanta, GA BlueChoice HealthCare Plan BlueChoice Option Blue Direct Patient s Name Member s Name Primary Contract Number Primary Group Number Secondary Contract Number Secondary Group Number / / / / Claim Number Admission Date Discharge Date Please indicate below why this refund is being sent back to us. A B C Our records indicate that this patient was not treated at our facility during the time these services were rendered. This payment has previously been made by Blue Cross Blue Shield Healthcare Plan of Georgia for the same dates of service and amount: Initial payment made on / / in the amount of $. Final payment made on / / in the amount of $. Blue Cross Blue Shield Healthcare Plan of Georgia is the secondary (COB) insurance carrier. is the primary carrier and they made payment on / / in the amount of $ I am refunding: Total amount paid by Blue Cross Blue Shield Healthcare Plan of Georgia Difference between primary and secondary payments. $ Amount of Refund D Other, Please Explain: E Provider Representative: 28 Rev 11/2005

32 EDI Services EDI Services Georgia, a division of Blue Cross and Blue Shield of Georgia, specializes in offering automated solutions to hospitals, physician practices and ancillary providers. EDI Services Department is dedicated to providing quality solutions to both Professional and Institutional customers. EDI Services Georgia has over twenty (20) years experience supporting electronic claims submission and other Electronic Data Interchange (EDI) transactions. EDI Services Georgia support all ANSI 4010A1 Transactions: 837 HealthCare Claim (Institutional, Professional, Encounters & Dental) 835 ERA (Electronic Remittance Advice) 270/271 Real Time & Batch Eligibility Request and Response 276/277 Real Time & Batch Claim Status Request and Response 278 Real Time & Batch Referral/Authorization Request and Response For electronic connectivity and submissions, please contact EDI Services at , Option 1 to obtain the required paper work or to answer questions regarding electronic data interchange (EDI). EDI support electronic transactions via a clearinghouse or direct from providers. 29 Rev 11/2005

33 Preferred Drug List Overview The objective of the Preferred Drug List (often referred to as Preferred Drug Formulary ) is to ensure quality and cost-effective prescription drug coverage at an affordable price for our members. The Pharmacy and Therapeutics (P&T) Committee of BCBSGa/BCBSHP, composed of practicing BCBSGa/BCBSHP physicians and pharmacists from around the state, has selected safe and effective products for coverage under the Preferred Drug List. The Preferred Drug List is supported by sound medical guidelines and treatment protocols researched from current pharmacological literature, reference books and peer-reviewed journals. The Preferred Drug List includes coverage for single source brand name drugs and generic equivalent products for those multi-source agents. The Preferred Drug List also targets our top 23 therapeutic categories. Within the top 23 classes, single source brand name drugs are limited to a specific list. Those drugs not included on the total Preferred Drug List are considered non-preferred or nonformulary. Non-preferred agents are not considered a covered prescription benefit unless they meet criteria established by the P&T Committee. The BCBSGa/BCBSHP Prescription Drug Program provides an exception process to provide coverage for a non-preferred drug prescribed by you when, in your professional judgment, no effective alternative is available on the Preferred Drug List. This process documents the need for an exception when a formulary/preferred product has been proven to be ineffective or causes adverse or harmful reactions to the patient. Following is a copy of the form required for the exception process. As a participating BCBSHP provider, you are asked to prescribe products from the Preferred Drug List for all BCBSGaBCBSHP members. By prescribing preferred drugs when appropriate, you help contain the rising costs of health care, ensure the use of high quality pharmaceuticals, and help maintain your patients continued drug coverage. We also ask that you assure your patients of the safety and efficacy of generic equivalents. Please use the Preferred Drug List when prescribing for your BCBSGa/BCBSHP patients. To receive a copy of the most current Preferred Drug List, please go to or contact your local Senior Network Specialist. 30 Rev 11/2005

34 Mail Order Prescription Drug Program BCBSHP members covered under BCBSHP Prescription Drug Program may have Preferred Drug maintenance prescriptions filled through Precision RX Mail Service Pharmacy. Maintenance drugs are determined by the First Data Bank which is considered an industry standard in defining maintenance and non-maintenance drugs. Maintenance drugs are defined as: approved by the FDA for long-term use for chronic conditions; considered reasonably safe when dispensed in large quantities of up to a 90-day supply; and must not have a potential for abuse. The benefits of allowing maintenance drugs only through the mail order include: Enhanced safety when prescribing acute medications resulting from the ability of the PCP to monitor dosage over a shorter period of time Reduced waste Improving optimal outcome for acute medications by eliminating delay in filling prescriptions through the mail order Maintenance prescriptions may be written for up to a 90 day supply with refills. For NEW maintenance medications it is recommended that the PCP write two prescriptions: 1. one for up to a 90-day* supply plus refills, to be mailed to PrecisionRX; and 2. a second, for a 30-day supply, to be filled immediately at a retail pharmacy. *Note: By law, PrecisionRX must fill the prescription for the exact quantity of medication prescribed (e.g., 30 days plus two refills does not equal one prescription written for 90 days. ) BlueChoice providers and members may call BCBSHP Customer Service regarding this program. 31 Rev 11/2005

35 BlueCard Program The Blue Cross and Blue Shield Association s BlueCard program allows physicians to file inpatient, outpatient, and professional claims with BCBSHP for members who are covered by other Blue Cross and/or Blue Shield plans. Through a single electronic network for claims processing and reimbursement, this program links physicians with other Blue Cross and Blue Shield plans across the country. BCBSHP remains the sole contact for claims submissions, payments, adjustments, services, and inquiries about the BlueCard program. Here s how the BlueCard program works: A member visits the physician s office and presents an ID card with a blank suitcase logo. (Not all HMO members are BlueCard members only those whose membership card displays the suitcase logo.) Look for the three-character alpha prefix that precedes the ID number on the card. The alpha prefix shows the patient is a member of the BlueCard program and identifies his or her plan or national account. This information is important to routing out-of-area claims. Once the alpha prefix is identified, member eligibility may be verified via on the Provider Access page, under Eligibility. The alpha prefix, member ID number, and date of birth are required. See the Provider Access section of this manual for more details. Eligibility can also be verified by calling BLUE (2583) from 8 AM to 10 PM. The alpha prefix and member ID number are required, and alpha characters must be converted to numbers for entry. If there is no alpha prefix, the member s claims are handled outside the BlueCard program. BlueCard out-of-area members are responsible for obtaining preauthorization from their own Blue Cross and/or Blue Shield plan. Once the member receives care, his or her claim should be submitted to BCBSHP. Again, the alpha prefix and complete ID number are required. Incorrect or missing alpha prefixes and member ID numbers delay claims processing. When BCBSHP receives the claim, it is electronically routed to the member s Blue Cross and/or Blue Shield plan. The member s plan processes the claim and approves payment. BCBSHP then pays the physician according to his or her contract. 32 Rev 11/2005

36 Provider Directory BCBSGa/BCBSHP provider directories are available to groups covered by BCBSGa/BCBSHP and to Network Providers. Members are encouraged to use innetwork providers in order to maximize their health care benefits, and Network Providers are required to direct members to in-network providers when ordering hospital inpatient or outpatient services and when referring members to other physicians for specialty care services. The provider directory is an essential tool for members and providers to ensure that members have the greatest opportunity to select and utilize a BCBSGa/BCBSHP provider. Each physician should check the accuracy of his/her listing in the provider directory. If errors are identified and need to be corrected, or if practice locations need to be added or deleted, please complete the Provider Information Change Form which may be found in the Provider Corner of the BCBSGa/BCBSHP web page, or contact your local Senior Network Specialist. Erroneous or incomplete provider information may result in lost patient referrals as well as delayed or improper claim payment. BCBSGa/BCBSHP s provider directories are updated, reprinted and furnished to providers periodically. To receive a current provider directory, call your local Senior Network Specialist. The most current version of the PPO and HMO provider directories is also available on our web site 33 Rev 11/2005