2012 ALL PAYERS WORKSHOP BLUE CROSS AND BLUE SHIELD OF KANSAS AGENDA

Transcription

1 2012 ALL PAYERS WORKSHOP BLUE CROSS AND BLUE SHIELD OF KANSAS AGENDA Connecting with Providers Other Party Liability (OPL) Quality Based Reimbursement Program (QBRP) Electronic Data Interchange (EDI) 1

2 Blue Cross and Blue Shield of Kansas Connected to our Providers Provider Representative o Phone Call your BCBSKS Rep for inquiries Conference Call o Fax o o Provider Visits One-on-one By Facility Department Training o Workshops o Web-based Training Modules enews o Newsletter o Latest News o Medical Policies o Website Updates BCBSKS Website ( o Inquiries/Secure Web Form o Manuals BlueAccess o Policies & Procedures o Precertification o Remittance Advice Availity o Eligibility o Claim Status Webinars KHA Convention All Payers Workshop BCBSKS Contact Information on the Web o Provider Representative o Education Coordinator o Claims Research Analyst o EDI o Professional Relations Hotline o Customer Service Center o Other Party Liability (OPL) o Federal Employee Program (FEP) o BlueCard o Precertification Department o Health Information Systems o TRICARE o New Directions 2

3 BLUE CROSS AND BLUE SHIELD OF KANSAS Other Party Liability (OPL) The BCBSKS OPL Department focuses on cost containment by coordinating payments between carriers. This saves millions of dollars each year. To contain costs, Blue Cross and Blue Shield of Kansas group health contracts include a non-duplication of benefits provision. This ensures that our customers do not receive duplicate payments for the same claim through multiple group health insurance carriers. Payment between two (or more) carriers may not exceed the total charge of the claim. Most contracts also include exclusions which deny benefits for services eligible under a Worker's Compensation law or No-Fault Automobile insurance. Duplicate Coverage Duplicate coverage applies when a patient is covered under more than one group health insurance carrier. Benefits are coordinated by the secondary carrier to prevent duplicating payment for the same service made by the primary insurer. Duplicate coverage is investigated on all new group family contracts. Follow up investigations are conducted every 15 to 18 months on those members who have indicated they have no duplicate coverage. Since 2008, Other Party Liability (OPL) will not delay claims for response to a routine duplicate coverage questionnaire. However, FEP policies, large dollar claims, member pay and third party payees are excluded. When duplicate coverage exists, a claim should be filed to all carriers (except in the case of multiple Blue Cross and Blue Shield of Kansas group policies, when only one is necessary). The Order of Benefit 3

4 Determination rule establishes a patient's primary carrier. Once provided proof of primary payment, the secondary carrier will process balances still owed by the patient for eligible benefits. A copy of the actual primary Explanation of Benefits (EOB) should be submitted as proof of primary payment, unless filing electronically. The electronic 837 claim format includes specific fields for reporting other insurance information. Claims must be filed to all carriers involved within the specified timely filing period of each. Maintenance of Benefits (MOB) ASO (Administrative Services Only) and out-of-area groups may choose to apply Maintenance of Benefits to dual coverage, rather than the standard Coordination of Benefits (COB) regulated by the NAIC and State Model. MOB does not apply to Benefit Determination Period nor does it ever allow the combined payments of carriers to exceed the allowable charge, regardless of the provider's contracting status. In some instances, the group has elected to hold the combined payments to the amount payable by their policy as if it were the only insurance coverage available. Groups currently using MOB include OneOK and the Federal Employee Program (FEP). Accidents Accidents and other diagnosis frequently identified as being work or automobile related (including back problems, carpal tunnel, heart attacks and hernias) are investigated for the possibility of another carrier who may be liable. Claims meeting the dollar threshold set by a Plan are reviewed for information regarding the date, place and circumstances of injury or onset of illness. If none exists, a questionnaire is sent to the member. Medical records are accepted in lieu of the member's response when necessary details are present. The member s file is updated after an investigation has been completed to prevent multiple investigations of the same accident or condition. 4

5 Worker's Compensation Worker's Compensation insurance provides benefits when an employee suffers a job related injury or illness. Blue Cross and Blue Shield of Kansas excludes coverage for services covered (or required to be covered) under a worker's compensation law. If the employee receives services from an unauthorized provider, or enters into a settlement giving up their right to future medical benefits, related claims will not be eligible under their BCBSKS policy. A letter of denial or release from the worker's compensation carrier should be forwarded to BCBSKS for reconsideration when applicable. Auto No-Fault Auto No-Fault or Personal Injury Protection (PIP) insurance benefits apply to any accidental bodily injury that arises out of the ownership, operation, maintenance or use of a motor vehicle. Those benefits must be completely exhausted before BCBSKS can determine what, if any, benefits BCBSKS will pay. A letter of denial or itemized statement of PIP and Excess Medical payments is necessary to make that determination. The OPL Web Questionnaire The OPL Questionnaire is available for our providers on the web at It is recommended that providers ask patients insured by BCBSKS to fill out the BCBSKS OPL web form with their other paperwork during a provider visit. This enables the provider to mail or fax the completed form prior to claim submission; providers can avoid delays otherwise caused when an OPL investigation is necessary. 5

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7 Providers may also directly submit the information electronically via the web at 7

8 The Remittance Advice (RA) The RA for secondary payments will show, not only the amount paid on the secondary claim, but also the total amount paid by the primary carrier, the total amount of patient responsibility, and the total provider write-off after taking into consideration the benefits of both carriers. This eliminates the need to retrieve the primary carrier EOB for balancing patient accounts. There are specific coding combinations on the Remittance Advice that help to identify a claim involving Other Party Liability. To identify an OPL claim on the RA the CNTR column will state OP. The OPL Adjustment Reason Code (ARC) and Remarks on the RA for OPL claims are listed in the table below with the code defined. ARC Remarks Code Definition 19 MA04 This service is due to a job-related illness or injury covered by Worker's Compensation. 21 MA04 The services are Motor Vehicle related 22 MA04 22 N48 The Primary Carrier must process first and an Explanation of Benefits from the Primary Carrier is required. The Explanation of Benefits (EOB) from the Primary Carrier does not match this claim. 23 Paid as secondary carrier 23 MA04 23 M N179 For FEP Members: Contact OPL Dept FAX The patient has accepted a financial settlement from another insurance company for this claim The Primary Carrier's payment exceeds the amount payable under the patient's contract. No Secondary Carrier payment is available on this claim. Awaiting a response to an OPL Questionnaire sent to the patient 8

9 Provider Remittance Advice Examples for Other Party Liability (OPL) Awaiting a response to an Other Party Liability questionnaire sent to the patient. CNTR = OP ARC = 227 (FEP ARC = 16) Remit Remark = N179 9

10 Provider Remittance Advice Examples for Other Party Liability (OPL) Paid as secondary carrier CNTR = OP ARC = 23 (FEP: call OPL) 10

11 Primary carrier EOB from example above: COB: Duplicate coverage secondary payment formula: Secondary balance - the amount owed by the patient after the primary payment. Secondary payment -the secondary balance, not to exceed the amount payable as primary. Provider s Contractual Obligation - the primary carrier s write-off will be enforced. Exceptions: 1) Secondary balance exceeds the BCBSKS allowed amount 2) Provider has no contracting arrangement with the primary carrier Amount Patient Owes - remaining balance. Note: MOB groups determine their own secondary payment rules Workers Compensation: Services not work related must be submitted on a separate claim from those services that are eligible under workers compensation law. No Fault: Payment after exhausting auto insurance (PIP) benefits is subject to member s contractual cost sharing (deductibles, coinsurance, etc.). 11

12 BLUE CROSS AND BLUE SHIELD OF KANSAS Quality Based Reimbursement Program (QBRP) BACKGROUND QBRP is an element of the Patient Protection and Affordable Care Act (also known as Healthcare Reform). It requires health plans to have a reimbursement arrangement that incentivizes quality. QBRP is a requirement for a health plan to be eligible to participate on the Health Insurance Exchange. EXCHANGE TIMELINE The Exchange takes effect in 2014 Health plan s quality incentive programs will be evaluated for approval in QBRP CRITERIA FOR 2013 BCBSKS worked with Kansas hospitals, Kansas Hospital Association and the Kansas Healthcare Collaborative to develop our QBRP. The goal is to associate provider's performance with monetary incentives so that, in turn, the provider's quality, safety and affordability continually improve. 12

13 QUALITY MEASURES: 3 Prerequisites 1. File claims electronically 2. Accept electronic remittance advices through the ANSI835 transaction or retrieve remittance advices from the BCBSKS website 3. Use the BCBSKS electronic portal for inpatient hospital precertification and continued stay reviews 7 Quality Measures 3 measures require a signed attestation form only and 4 measures require reporting. Process oriented vs. outcome based Incentive payment is not based on the scores submitted QBRP TIMELINE: A one-time attestation form and information required for quality measures were due December 1, 2012 Updated information must be received no later than May 15, 2013 Failure to report information by May 15, 2013 will result in the reduction of the incentive previously given 13

14 TriWest Transition Frequently Asked Questions Q. I'm a current TRICARE network provider. How do I contract with UnitedHealthcare so that I may continue serving TRICARE beneficiaries? A. We appreciate your interest in participating in the UnitedHealthcare provider network for TRICARE and we value your service to TRICARE beneficiaries. Our primary goal is minimizing beneficiary disruption in access to care and services. UnitedHealthcare will be sending all currently participating TRICARE network providers a contract offer, with the majority of offers being mailed throughout the end of October. Q. Is there a deadline to return the documents? A. It is recommended to return the documents as soon as possible, but no later than December 15, 2012, to ensure each provider is set-up in time for health care delivery on April 1, Q. Will I have to accept all UnitedHealthcare members if I sign a TRICARE contract with UnitedHealthcare? A. No. Our primary goal is to ensure TRICARE beneficiaries continue to be able to access their current provider network. At this time, all UnitedHealthcare contracting activities are specific to TRICARE program participation only. Q. I'm not currently part of the TRICARE network but would like to be, how do I join? A. We appreciate your interest in participation in the UnitedHealthcare TRICARE network. If you are a medical provider, please contact A member from the UnitedHealthcare provider relations team will contact you. If you are a behavioral health provider, send an message to the UnitedHealthcare behavioral health provider relations team at: tricare_bhrecruitment@optum.com. Q. What credentialing activities will be required? A. In addition to becoming a certified provider, providers interested in signing a contract and becoming a member of the TRICARE network must be credentialed by UnitedHealthcare. The credentialing process involves obtaining primary-source verification of the provider's education, board certification, license, professional background, malpractice history, and other 14

15 pertinent data. If you are already a UnitedHealthcare participating provider, we will utilize the credentialing information we already have on file. Should we identify additional requirements necessary to participate in the TRICARE program, we will reach out directly to you to obtain such information. If you are not already a participating provider, you will be required to submit a completed application, including all necessary supporting information, and successfully complete the credentialing process before a contract can be executed. Q. What rates will UnitedHealthcare offer to providers? A. UnitedHealthcare Military & Veterans is committed to balancing the delivery of a competitively priced network to the Military Health System with fair compensation to the provider community as they provide healthcare services to the most important of beneficiaries - the men and women of our military and their families. If you are a current TRICARE provider, you will receive your rate offer with your contract documents by the end of October. Q. I'm in the middle of an appeal with TriWest; who finishes my appeal when the West region moves under UnitedHealthcare Military & Veterans? A. TriWest s regional claims processor will finish appeals sent to TriWest. Q. I currently have an authorization from TriWest to see a specialist. What happens when the contract changes from TriWest to UnitedHealthcare Military & Veterans in the West region? Do I need a new authorization? A. Authorizations approved by TriWest will be valid until the end date on the authorization, or May 30, 2013, whichever comes earlier. Exception: TriWest and UnitedHealthcare agreed to honor existing authorizations for maternity care for the mother s entire 312 day episode of care, based on the start date. Before March 31, 2013, you may need to get a new authorization from UnitedHealthcare Military & Veterans if you need care beyond May 30, We'll have more details about this process closer to March, Note: At this time, you don't need to contact UnitedHealthcare about TriWest authorizations. Q. Is it true that TriWest is no longer the West region contractor? A. Actually, TriWest s current TRICARE contract continues through March 31, Effective April 1, 2013, UnitedHealthcare Military & Veterans will be the new contractor for the West region. 15