BCBSNC Welcome! Health Insurance Institute North Carolina Healthcare Financial Management Association

Transcription

1 BCBSNC Welcome! Health Insurance Institute 2010 North Carolina Healthcare Financial Management Association

2 Workshop Overview HealthCare Reform ICD-10 Inter-Plan Programs Blue Medicare HMO/PPO Federal Employee Program State Health Plan PPO Updates and Reminders HIPAA 5010 Web Resources 2

3 HealthCare Reform 3

4 Health Care Reform Health care reform became a reality with the passage of two related bills: The Patient Protection and Affordable Care Act (PPACA) The Health Care and Education Reconciliation Act Because these two bills work together, we often refer to health care reform as a single "new law" for the sake of simplicity. 4

5 Health care reform law has many separate provisions that will come into effect at different times over the next eight years. Here are some of the most important ones: Individual Mandate Subsidies to make insurance more affordable Expanded Eligibility for Medicaid New Insurance Rules Exchanges Preventative Care Increased Prescription Assistance 5

6 These are the most significant and talked-about provisions of health care reform, but the new law contains many other detailed changes to the way health care is developed, delivered and paid for in America. Health care reform will change the way people buy and use health care in a number of ways. BCBSNC has established a website to assist all North Carolinians with understanding the impact of health care reform - 6

7 ICD-10 7

8 ICD-10: Federal Mandate ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, Otherwise, claims and other transactions will be rejected, and will need to be resubmitted. It is important to begin preparing for the implementation of ICD-10 codes. Delays may impact your reimbursements. 8

9 ICD-10: Summary Today: ICD-9 ICD-9-CM vol. 1 & 2 (Diagnosis) 3-5 digits (e.g., Closed Fracture of shaft of femur) ~13,500 unique codes ICD-9-CM vol. 3 (Procedure) 3-4 digits (e.g., Laparoscopic appendectomy) ~4,000 unique codes Tomorrow: ICD-10 ICD-10-CM (Diagnosis) 3-6 alphanumeric plus qualifier (e.g., S Displaced spiral fracture of shaft of right femur) ~68,000 unique codes ICD-10-PCS (Procedure) 7 alphanumeric (e.g., ODTJ4ZZ Laparoscopic appendectomy) ~72,000 unique codes 9

10 ICD-10: Important payment impacts Supports Timely Reimbursements Use of HIPAA 5010 transactions Changing business processes to describe diagnosis using ICD-10-CM Changing inpatient business processes to describe inpatient procedures using ICD-10-PCS Impacts to Reimbursement Use of ICD-9 after 10/1/2013 The use of truncated codes Use of Not Otherwise Specified codes where specificity is available To be compliant with Federal regulations, BCBSNC will only accept claims with ICD-10 diagnosis codes for services rendered on or after 10/1/2013. To be compliant with Federal regulations, BCBSNC will only accept claims with inpatient procedures that have been coded using ICD-10 for services rendered on or after 10/1/

11 ICD-10 Summary ICD-10 will allow extensive detail and flexibility for use in describing disease states. 3-7 characters and 68,000 codes The switch to using ICD-10 will change the way providers describe patient diagnosis and inpatient procedures. Timeline for implementation 10/1/2013. All claims with dates of service prior to 10/1/13 use ICD-9, all dates after 10/1/13 use ICD

12 ICD-10 Resources CMS: AHA: 10/ICD-10.jsp AHIMA: AAPC: NCHICA: 12

13 Inter-Plan Programs (BlueCard ) 13

14 IPP Medical Policy and Prior Review Router Effective Oct. 1, 2010, providers will have access to medical policies and general prior review requirements from the member s Home Plan: You will enter alpha prefix in a designated area(s) on the local Plan s Web site ( Provider will then be routed to the Home Plan s medical policy and/or prior review requirements. Once medical policy and prior review requirements are viewed, provider will then be reconnected back to the BCBSNC website. 14

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18 Blue Medicare HMO Blue Medicare PPO 18

19 Blue Medicare HMO and PPO Member ID cards Blue Medicare HMO and PPO alpha prefix: YPWJ YPFJ Blue Medicare HMO and Blue Medicare PPO designation BCBSNC The ID cards are readily recognizable and display information specific to the Blue Medicare HMO and Blue Medicare PPO products. 19

20 How to reach Blue Medicare HMO and PPO BCBSNC claims mailing address if not filing electronically Blue Medicare HMO and Blue Medicare PPO Provider Service Line and contact information The cards display Blue Medicare HMO and Blue Medicare PPO claims mailing address and telephone service lines 20

21 Blue Medicare Diagnostic Imaging Management (DIM) Program Effective for dates of service on or after September 1, 2010, for members covered under Blue Medicare HMO and Blue Medicare PPO, providers will now be required to comply with the DIM program for the outpatient diagnostic imaging services listed below when performed in a physician's office, outpatient department of a hospital, or freestanding imaging center. CT/CTA scans MRI/MRA scans Nuclear cardiology studies PET scans 21

22 Federal Employee Program (FEP) 22

23 Free Physical Exam/Blue Health Assessment This certificate entitles FEP members to receive a physical exam at no charge. To ensure correct reimbursement, the claim must be filed with the appropriate diagnosis and procedure code to reflect the visit was a routine/annual exam. 23

24 State Health Plan PPO 24

25 Subrogation The State Health Plan (the Plan) has the right of subrogation upon Plan members right to recovery from liable third parties for medical expenses, including provider, hospital, surgical, or prescription drug expenses. The Plan s objective is to recover medical expenditures paid by the Plan where a third party is liable for the care. The recovering of these expenditures will ensure the financial stability of the Plan and allow for continued cost-efficient health care for its members

26 Subrogation continued. As a provider, what should we do? Be cognizant of patients whose injuries are a result of a car crash, slip and fall accident, medical malpractice, product liability, assault, or nursing home accident. If you provide a service for a Plan member or the member s dependent for injuries related to an accident or Workers Compensation, then contact Health Management Systems (HMS) at

27 Updates and Reminders 27

28 Universal Flu Vaccine and High Dose Flu Vaccine Fluzone (regular) - this is the combo vaccine with 2 strains of influenza + H1N1 called trivalent vaccine : CPT codes (depending on age and if it s preservative free or not) Fluzone High Dose this is for use in people age 65 years and older : CPT code

29 Flu Vaccine Administration Administration codes for influenza vaccine: CPT depending on age, route of administration and if single or multiple vaccines given. CPT codes pertain to children less than 8 yrs; CPT codes are for 8 yrs and older. If the member also has Medicare coverage, providers should use administration code G0008 because Medicare requires this administration code for the influenza vaccine. 29

30 Hearing Aid Mandate Effective 1/1/2011 or upon a group s renewal, all plans (group and individual) will provide coverage for one (1) hearing aid per hearing-impaired ear up to $2,500 per hearing aid every 36 months for covered members under the age of 22 years. Hearing Aid coverage will include all medically necessary hearing aids and services that are ordered by a physician or an audiologist licensed in the state. Where appropriate, providers will be required to file with the appropriate LT and/or RT modifier when filing claims. This does not apply to FEP members. 30

31 Claims Payment Consolidation Effective 10/15/2010, BCBSNC will start decreasing the number of times each week we make payments for certain lines of business. Consolidation of claims payments and reductions in the number of claims payment runs will allow BCBSNC the needed time to repair any claims before payments are sent, increase accuracy of payments and ultimately result in fewer claims adjustments and refund requests made to you, our providers. 31

32 Concurrent Review BCBSNC is re-implementing concurrent review functions as part of our Healthcare Management and Operations program at acute care facilities effective September 1, The goal of concurrent review is to: identify timely discharge needs promote improved facilitation of discharges gain administrative efficiencies for both organizations, with an ultimate goal of improving overall member satisfaction. 32

33 Claims Timely Filing Guidelines Professional & Facility claims must be submitted within 180 days of services being rendered or the date of discharge, with the exception of claims for FEP members. Claims for FEP members must be filed by December 31 of the year after services were rendered or date of discharge. 33

34 Spanish speaking patients Web site: Spanish-speaking customer service

35 Available on the Web Online resources bcbsnc.com/providers/ We re serious about health care reform. Here s how to make it work. 35

36 BCBSNC Provider Survey Your opinion matters to us! We care about what you think and we want to hear of your experience as an in-network provider delivering care to Blue Cross and Blue Shield of North Carolina (BCBSNC) members. We re asking you to please tell us! The survey link will be available beginning Monday 9/20/10 on the BCBSNC provider site ( please take a few minutes from your day and respond to our survey. 36

37 HIPAA

38 HIPAA What is HIPAA 5010? In January 2009, the US Health and Human Services (HHS) released two final rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Updating standards for electronic health care transactions: Replace all HIPAA X12 version 4010A1 transactions with version 5010 by 1/1/2012 Code Sets and International Classification of Diseases (ICD-10) Pre-cursor for ICD-10 reporting 38

39 Why is 5010 Important? ANSI X12 standard transactions give us a common language to use as we increase levels of automation in eligibility and claims management Sound ecommerce practices are required for continuation in federally funded programs It makes good business sense to be compliant 39

40 5010 Impacts all x12 Provider Transaction Standards Claims Institutional, Professional, and Dental (837I,P,D) Eligibility Request and Response (270/271) Payment/Remittance Advice (835) Claims Status Inquiry and Response (276/277) Authorization/Referral Request and Response (278) 40

41 HIPAA Timeline Level 1 Compliance January 1, 2011 (Complete Internal Testing) Internal system changes complete, tested, and in production Ready for Trading Partner testing Ready for Trading Partner roll out Dual Use January 1, 2011 December 31, 2011 (Begin External Testing and Complete Testing with Trading Partners) Accept/send either 4010A1 or 5010 in production Based on Trading Partner request/readiness Level 2 Compliance January 1, 2012 (All covered entities must be fully compliant) Accept 5010 ONLY 41

42 HIPAA Resources CMS Educational Resources: 5010 Fact Sheet and Checklist sources.asp WEDI HIPAA 5010 Resources CBSNC Web Content 42

43 HIPAA Resources Companion Guides Available 10/1/10 for HIPAA 837, and 270/271 transactions Available 11/1/10 for HIPAA 835 transaction 43

44 BCBSNC s Approach to 5010 Transition Transaction rollout based on volume and Trading Partner prioritization. Communicate with all Trading Partners when BCBSNC is ready for testing and migration Roll out HIPAA 5010 to all Trading Partners by end of 2011 Target completion date of roll out is 10/31/2011 to avoid holiday impacts Set-up of new Trading Partners in 5010 only after 11/01/11 BCBSNC in dual use throughout

45 2011 Timeline for 5010 Transition 5010 Roll out for 837 Claims, 270/271 Eligibility and 835 Remittances will begin First Quarter Roll out for 276/277 Claim Status and 278 Authorizations will begin July

46 HIPAA 5010 Transition: What Should Providers Be Doing Now? Contact other trading partners, software vendors, and payers to understand their individual timelines Review 5010 educational materials at the U.S. Department of Health & Human Services website located at: ces.asp 46

47 HIPAA 5010 Transition: What Should Providers Be Doing Now? Prepare to test your readiness to send/receive HIPAA transactions For BCBSNC, you can access our testing site through Assess operational impacts of the 5010 transition Use 5010 as an opportunity to expand automation and improve work processes! 47

48 Web Resources *Blue e 48

49 Blue e Enhancements (Target 4 th Q 2010) Expand CMS1500 field 24G to display all 5 characters allowed for entry. On UB04 require CPT and HCPS codes to be entered at line level for hospitals and ambulatory surgery centers. Add a link to BCBSNC Medical Policy on Health Eligibility. In Health Eligibility, change "Eligibility for" to read "Member Policy Effective Dates: mm/dd/ccyy - mm/dd/ccyy". 49

50 Blue e Enhancements (target 2011) In Health Eligibility, add an indicator to show if the member is enrolled in Member Health Partnerships (Targeted 1 st Q 2011). Claim Status- improved responses around Medical Records and COB information (Targeted 1st Q 2011). capability now exists for assistance with Blue e Access the Resource Tab from the Home Page. Click on the link that best identifies the question or issue. A Help Desk Analyst will respond to your request within two business days. 50

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53 Explanation of Payment (EOP) Suppression BCBSNC will change the standard delivery of paper remittances for providers with Blue e access Includes paper EOPs, voided checks (EFT providers), and summary pages for all BCBSNC Commercial business Change will occur in phases Institutional providers in October, 2010 Professional providers in November,

54 EOP Suppression Federal Employee Program and Medicare Supplemental remittances will continue to be mailed. BCBSNC offers multiple solutions for receiving remittance information. 1. Access Remittance Inquiry link via Blue e to view, save, or print your own remittance advice or NOP/EOP. Retrieve EOP information for up to 365 days. 2. Utilize the HIPAA 835 electronic remittance. 54

55 Contact Information esolutions Help Desk Provider Service Consultants Asheville West (Charlotte) Triad/Triangle East Wilmington

56 Test Your Understanding only affects the Claim/Encounter (837) transaction. True/False 2. Replacement of all HIPAA X12 transactions to version 5010 is required for all covered entities by 1/1/2011. True/False 3. After January 1, 2012, only version 5010 will be accepted. True/False 56

57 Test Your Understanding continued 4. ICD10 compliance date occurs before the 5010 compliance date of January 1, True/False 5. Blue Medicare Supplement and Federal Employee paper remittances will continue to be mailed after November True/False 57

58 Questions? Thank you! 58