What Blue Cross provider networks are used for the OGB benefit plans and how can I find other OG network providers for my patients?

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Lynne Morton
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1 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions GENERAL Who is OGB? Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB The (OGB) is n gency of the Stte of Louisin within the Office of the Governor, Division of Administrtion. OGB is uthorized by sttute to provide helth nd ccidentl benefits nd life insurnce, nd Flexible Benefits pln to Stte employees, retirees nd their dependents. Pln prticiption eligibility include employees of Stte gencies, institutions of high eduction, locl school bords tht elect to prticipte in the Progrm nd certin politicl subdivisions. Eligibility does not include locl government entities or municiplities. The OGB is considered Progrm within the Division of Administrtion. OGB is proud to hve served employees nd retirees of the Stte of Louisin for more thn 40 yers. Wht re the benefit plns tht Blue Cross dministers for OGB members? Beginning Mrch 1, 2015, Blue Cross dministers the following benefit plns for Stte of Louisin employees, retirees nd dependents: Pelicn HRA 1000 Pelicn HSA 775* Mgnoli Locl Mgnoli Locl Plus Mgnoli Open Access While none of the Mrch 1, 2015, plns re exctly the sme s the plns offered in 2014, some of the choices re very similr. Ech pln utilizes network tht is lredy in plce. There re no new networks providers must join to be innetwork for OGB The three OGB benefi t plns in plce for 2014 nd through the end of Februry 2015 re no longer vilble s of Mrch 1, *Only vilble to ctive employees. PROVIDER NETWORKS Wht Blue Cross provider networks re used for the OGB benefit plns nd how cn I find other OG network providers for my ptients? You my use our online provider directory tool, vilble t to locte network providers for OGB To ensure OGB members ccess the correct provider network, OGB networks re listed by product nme (rther thn network nme) in the drop-down box of our online directory tool. Pelicn HRA utilizes the OGB Preferred Cre** network Pelicn HSA utilizes the OGB Preferred Cre** network Mgnoli Locl - utilizes either the BlueConnect or Community Blue network Mgnoli Locl Plus - utilizes the OGB Preferred Cre** network Mgnoli Open Access - utilizes the OGB Preferred Cre** network **The OGB Preferred Cre network is Blue Cross network of Preferred Cre PPO providers. OGB members who ccess the OGB Preferred Cre network lso hve ccess to BlueCrd PPO providers ntionwide. Visit to view our online provider directory. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 1

2 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions BENEFIT PLANS Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB Wht re the lph prefixes for the OGB benefit plns? When cpturing member s policy number you cn distinguish the benefit pln by the first three lph positions of the policy number. LXS-Mgnoli Locl Community Blue (Bton Rouge nd Shreveport res) LZB-Mgnoli Locl BlueConnect (New Orlens re) OGS-ll other plns (Pelicn HRA 1000, Pelicn HSA 775, Mgnoli Locl Plus nd Mgnoli Open Access) Which OGB benefit plns re considered HMO plns? 1. The Mgnoli Locl benefit pln is n HMO pln design tht utilizes two HMO provider networks: Community Blue network - Avilble only to members in Bton Rouge nd Shreveport res(ascension, Bossier, Cddo, Est Bton Rouge nd West Bton Rouge prishes). BlueConnect network - Avilble only to members in New Orlens re (Jefferson, Orlens nd St. Tmmny prishes). 2. The Mgnoli Locl Plus benefit pln is n HMO pln design tht utilizes the OGB Preferred Cre network. Cn Mgnoli Locl member in the Bton Rouge or Shreveport re see BlueConnect network provider? Cn Mgnoli Locl member in the New Orlens re see Community Blue network provider? Mgnoli Locl Community Blue members do not hve coverge if they choose to see BlueConnect providers. Mgnoli Locl BlueConnect members do not hve coverge if they choose to see Community Blue providers. Will n OGB Preferred Cre (sme s our Preferred Cre PPO) network provider, who is not prticipting in either the Community Blue or Blue Connect networks receive pyment for services rendered to Mgnoli Locl member? No. In order for member enrolled in the Mgnoli Locl pln to receive benefits they must receive services from provider contrcted in either the Community Blue or BlueConnect network. There re no non-network benefits vilble to Mgnoli Locl Are there ny Community Blue nd BlueConnect members, other thn OGB Mgnoli Locl enrollees, with nonnetwork benefits vilble? Yes. BCBSLA offers mny vritions on benefit designs for our Some Community Blue nd BlueConnect benefit plns include non-network benefits. For this reson, it is importnt to lwys hve the most ccurte benefits informtion bout member prior to rendering services. To do so, lwys sk for copy of the member s identifiction crd nd check ilinkblue for the most current benefits nd eligibility. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 2

3 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB How re the Pelicn HRA 1000 nd Pelicn HSA 775 benefit plns different? Below re the min differences between the Pelicn HRA 1000 nd Pelicn HSA 775 benefit plns. Pelicn HRA 1000 Pelicn HSA 775 Members Active Employees, Retirees nd Dependents Active Employees Only Phrmcy MedImpct Express Scripts, Inc. (ESI) Funding Clims Processing How does the HRA work? Includes helth reimbursement rrngement (HRA) tht is n employer contribution of $1000 for employee-only plns nd $2000 for fmily plns. The member out-of-pocket (cost shre) mount of clims will be pid directly by Blue Cross from the member s HRA ccount. Once the funds re exhusted from the HRA ccount, the member will then be responsible for pying their out-of-pocket (cost shre) mounts. Includes helth svings ccount tht is directly vilble to the member vi helth debit crd nd/ or checks. The HSA is consumer driven, mening tht the member cn use the HSA funds to py their cost shres or other qulified medicl expenses s they re incurred. The Pelicn HRA funds will py the member s out-of-pocket (cost shre) mount t the time the clim is processed by Blue Cross. This pyment will be reflected on the provider s remittnce dvice. The HRA funds re not eligible for use on wellness clims s they re covered t 100 percent. The funds re lso not eligible for use on phrmcy, dentl or vision clims. Below is n exmple of how the HRA works. Once the funds re exhusted, the member pys the cost shre. For members with the Pelicn HRA benefit pln, wht hppens if the provider collects the member s out-ofpocket (cost shre) t the time of service nd then it is pid by Blue Cross when the clim is processed? The collection of the member s cost shre should be considered s the overpyment mount nd should be refunded to the member within 30 dys of discovery of overpyment. For this reson, it is importnt tht providers use ilinkblue ( to determine the vilble HRA funds of the member prior to rendering services/collecting pyment from the member. Once the HRA funds show exhusted in ilinkblue, the provider should then collect the cost shre mount from the member. Exmple: HRA Funds Avilble HRA Funds Exhusted Clim Billed Amount $ $ Blue Cross Allowed $ out-of-pocket pid $ by Blue Cross / do Member Deductible Applied $ $ NOT collect from Blue Cross Pys $ member $ 0.00 out-of-pocket NOT pid by Blue Cross / collect from member The ilinkblue coverge summry nd clims sttus screens, provider remittnce dvices, the 270/271 eligibility trnsction nd the 835 electronic remittnce dvice reflect HRA blnces nd provider pyments issued from members HRA ccounts. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 3

Blue Cross OGB-Dedicted Customer Service: 1.800.392.4089 ogbhelp@bcbsl.

This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB Wht is the difference between the Mgnoli Locl

Unlike the Mgnoli Locl benefit pln, which is n HMO pln design on select HMO provider networks (Community Blue or BlueConnect), the Mgnoli Locl Plus is n HMO pln design on PPO network (the OGB

Wht is the Mgnoli Open Access benefit pln nd why re there different deductible mounts on these policies?

1, 2015, or retired on or fter Mrch 1, 2015. Alwys check ilinkblue (www.bcbsl.com/ilinkblue) for the most up-to-dte nd ccurte benefit informtion before rendering services.

4 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB Wht is the difference between the Mgnoli Locl benefit pln nd the Mgnoli Locl Plus benefit pln? Unlike the Mgnoli Locl benefit pln, which is n HMO pln design on select HMO provider networks (Community Blue or BlueConnect), the Mgnoli Locl Plus is n HMO pln design on PPO network (the OGB Preferred Cre network). Just s with the Mgnoli Locl benefit pln, Mgnoli Locl Plus members do not hve coverge for services performed by non-network providers. Wht is the Mgnoli Open Access benefit pln nd why re there different deductible mounts on these policies? The Mgnoli Open Access benefit pln is OGB s PPO-style benefit pln on PPO network (OGB Preferred Cre network) nd the deductible mounts vry bsed on whether the enrollee is ctive, retired prior to Mrch 1, 2015, or retired on or fter Mrch 1, Alwys check ilinkblue ( for the most up-to-dte nd ccurte benefit informtion before rendering services. Does Blue Cross utomticlly dd retiree to supplementl policy t the time of Medicre eligibility? No. All OGB eligibility is mnged directly by the. Blue Cross receives eligibility updtes from OGB. Alwys check ilinkblue for the most up-to-dte nd ccurte benefit nd eligibility informtion before rendering services. Did OGB members receive new ID crds for the new benefit plns effective Mrch 1, 2015? Yes. OGB members were issued new member identifiction (ID) crds for the five new benefit plns tht were effective Mrch 1, These new ID crds re for use for dtes of service on or fter Mrch 1, Smple Pelicn HRA 1000 ID Crd Smple Pelicn HSA 775 ID Crd Smple Mgnoli Locl Plus ID Crd Smple Mgnoli Locl ID Crd Smple Mgnoli Locl ID Crd Smple Mgnoli Open Access Crd ~BlueConnect~ ~Community Blue~ Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 4

5 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB AUTHORIZATIONS Wht services require n uthoriztion for OGB members? The list of services tht require n uthoriztion is the sme for ll OGB benefit plns nd is vilble in the OGB speed guide, s well s our provider mnuls. Filure to obtin prior uthoriztion, when required, will result in denil of pyment for services. Our provider mnuls nd the OGB speed guide re both vilble online t providers >Eduction on Demnd nd re lso vilble on ilinkblue ( On ilinkblue, the mnuls re under the Mnul section nd the OGB speed guide is under the Authoriztions nd Medicl Policies section, bsed on the member s lph prefix. The three OGB lph prefixes re LXS, LZB nd OGS. When Blue Cross uthorizes cre, is the uthoriztion n utomtic gurntee of pyment for services rendered? No. Authoriztion of services is not gurntee of pyment. Pyment depends on number of fctors including member eligibility, provider contrct sttus, nd benefit limits t the time cre is rendered. Do ll inptient dmissions require n uthoriztion? No. Mternity dmissions to in-network fcilities (or non-network fcilities if the member hs non-network benefits) do not require uthoriztion if the inptient sty is 48 hours or less for vginl delivery nd 96 hours or less for Cesren section delivery. Inptient services for newborn well-bby services re included in the mother s sty. However, uthoriztion is required for inptient sick-bby services. All other inptient dmissions, including those for trnsplnts, behviorl helth, etc., do require n uthoriztion. Are there ny new exclusions for the OGB benefits tht were effective Mrch 1, 2015? Yes. Effective Mrch 1, 2015, the following services were dded to the exclusion list for ll OGB benefit plns. For the complete list of excluded services, use ilinkblue. Acupuncture Infertility Services (This includes services nd complictions. OGB will only cover the initil dignosis.) Routine Vision Exms Services performed s result of compliction rising from non-covered services (complictions for Heds Up prticipnts re covered) Temporomndibulr Joint Disorders (TMJ) Wht does the exclusion listed s services performed s result of compliction men nd wht is the Heds Up progrm? Obesity/morbid obesity clims nd complictions from morbid obesity surgery re not covered on ny of OGB s benefit plns. However, IF the OGB member prticiptes in Pennington s Heds Up progrm AND OGB uthorizes the services, Blue Cross will py compliction clims for the member in the Heds Up progrm when pproved nd directed to do so by OGB. These clims re processed mnully nd re hndled outside of the norml clims filing process. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 5

6 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB If n OGB ptient comes in for n initil office visit for n erche nd the finl dignosis is determined to be TMJ, will the initil office visit be covered since TMJ is excluded from the OGB member s benefits? Yes, the initil office visit would be covered bsed on the primry dignosis of erche, however, with confirmed dignosis of TMJ, no future services would be llowed if it is excluded from the member s benefit pln. Is n uthoriztion required when Medicre is primry? An uthoriztion is not required when Medicre is primry nd the service is covered by Medicre. However, if the service is NOT covered benefit by Medicre nd the service is listed on the OGB uthoriztion list, then n uthoriztion is required since we re the primry pyer t tht point. Cn providers use ilinkblue to request n uthoriztion? Professionl providers should use ilinkblue to request uthoriztions for high-tech dignostic imging services (including but not limited to CT/CAT Scn, MRI/MRA, nucler Crdiology nd PET Scn). We re working with fcility providers to implement our online uthoriztion portl through ilinkblue to request n uthoriztion for inptient nd outptient services. The new Authoriztion Portl is vilble under the Authoriztion menu option of ilinkblue. While professionl providers cnnot yet use this tool to request n uthoriztion for services other thn high-tech dignostic imging services, Blue Cross is working to offer this tool to professionl providers by the end of Why doesn t the Blue Cross uthoriztion deprtment give us cll reference number when we cll for n uthoriztion? Your uthoriztion number is your cll reference number so no dditionl number is necessry. BEHAVIORAL HEALTH Are the behviorl helth benefits the sme for ll OGB members? No. Benefits re dministered nd clims re processed bsed on the member s benefit pln. The benefits, clims nd provider network for OGB s Pelicn HRA 1000, Pelicn HSA 775, Mgnoli Locl Plus nd Mgnoli Open Access benefits plns re hndled directly by Blue Cross. - Use ilinkblue or cll Blue Cross OGB-dedicted Customer service t for benefits. - Clims should be submitted directly to Blue Cross - Authoriztions only re hndled (for Blue Cross) directly by Mgelln Helth Services ( ) The benefits, clims nd provider network for OGB s Mgnoli Locl benefit pln is hndled directly by Mgelln Helth Services, Inc. - Contct Mgelln for benefits ( ) - Clims should be submitted directly to Mgelln (P.O. Box 1959, Mrylnd Heights, MO 63043) - Authoriztions re hndled directly by Mgelln ( ) Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 6

7 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions PHARMACY Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB Wht re the phrmcy crriers for the OGB benefit plns? OGB members use MedImpct or Express Scripts, Inc. (ESI), bsed on the OGB member s benefit pln: Pelicn HRA uses MedImpct. For uthoriztions, cll Pelicn HSA uses Express Scripts, Inc. For uthoriztions, cll Mgnoli Locl - uses MedImpct. For uthoriztions, cll Mgnoli Locl Plus - uses MedImpct. For uthoriztions, cll Mgnoli Open Access - uses MedImpct. For uthoriztions, cll Is Wlgreens phrmcy prt of the Express Scripts, Inc. nd MedImpct networks? For informtion bout the phrmcies included in ESI s nd MedImpct s network plese contct them directly: ESI or MedImpct or CLAIMS Where do I file OGB clims? Providers my submit clims electroniclly or hrdcopy. We offer two options for when filing electroniclly; through our ilinkblue Provider Suite or through your cleringhouse. More on our electronic services is vilble online t >I m Provider >Electronic Services. Hrdcopy Clims should be submitted directly to Blue Cross for processing (BCBSLA, P.O. Box 98029, Bton Rouge, LA ). Wht re the timely filing rules for OGB members? Clims filed for ll OGB members must be filed within 12 months of the dte of service. Clims received beyond the 12 month filing limit will be denied for timely filing. Wht is the time frme for OGB pyment recoupments? Is this from the dte of clim receipt or dte of pyment? For OGB members, clims reviews including refunds nd recoupments must be requested within 18 months of the receipt dte of the originl clim. When using cleringhouse to file clims electroniclly, pyer ID is required. Is there distinct pyer ID for OGB clims? No. A seprte pyer ID is not required for OGB clims. OGB clims should be included with your electronic file, the sme s for ll Blue Cross clims. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 7

8 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB MEDICAL RECORDS Do I hve to submit medicl records for OGB members? As prticipting provider, you gree to submit clims for Blue Cross nd Blue Shield members on the CMS-1500 Helth Insurnce Clim Form. All pplicble informtion should be completed in full, including CPT codes, ICD-9-CM dignosis codes nd pplicble medicl records to support the use of modifiers or unlisted codes with chrge greter thn $500 to ensure pyment is mde to you ccurtely nd without dely. This includes OGB How in-depth do medicl records hve to be for OGB members? The stndrd for medicl records for OGB members is the sme s for ny other Blue member. Medicl records must support ALL dignosis codes on clims. Cn I mnge medicl record requests electroniclly for OGB clims? Not t this time. Currently our ilinkblue Provider Portl includes feture for mnging online medicl record requests for out-of-stte (BlueCrd ) members, but it is not yet vilble for our locl Blue Cross nd HMOLA members (including OGB members). We relize this would be beneficil for ll Blue Cross members nd we re working to enhnce our cpbilities to upgrde this option in the future. COORDINATION OF BENEFITS Does Blue Cross ccept secondry coverge informtion for OGB members? Yes. Just s with ny other Blue member policy, when member hs benefits/coverge on more thn one insurnce policy, whether it be between two seprte insurnce compnies or two Blue policies, we will coordinte the benefits utomticlly. How does Blue Cross obtin the OGB member s other coverge informtion? OGB members must report their other coverge informtion directly to the humn resources deprtment of their employer/gency/etc. OGB therefter reports to Blue Cross the other coverge informtion of their members, which is used to coordinte clims pyments. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 8

9 Blue Cross OGB-Dedicted Customer Service: Frequently Asked uestions SUBROGATION Blue Cross nd Blue Shield of Louisin dministers helth benefits for (OGB s) stte of Louisin employees, retirees nd dependents. This document includes list of frequently sked questions bout OGB s benefit plns with Blue Cross to ssist your office when providing services to OGB Where should subrogtion (third-prty libility) clims be submitted for OGB members? Blue Cross is py nd pursue pln. Per your contrct greement, you gree to file clims for Blue members (including OGB members) directly to Blue Cross for the initil processing. Blue Cross will process nd py providers for their services nd pursue the responsible prty(ies) for their libility. SUPPORT Where cn I get more informtion bout provider requirements for OGB members? More informtion on OGB is included in our office mnuls nd OGB speed guide, vilble online t OGB nd >OGB. Who do I cll if I hve questions bout OGB members? If you hve questions tht re not covered in this document, our provider office mnuls or in the OGB speed guide, you my cll Blue Cross OGB-dedicted Customer Service or you my emil ogbhelp@bcbsl.com. Who do I cll if I hve questions bout network prticiption or in-service trining? If you hve ny questions bout your network prticiption, you my contct your Network Development representtive. For questions bout obtining in office trining, you my contct your Provider Reltions representtive. To find the representtive ssigned to your re, plese view the online provider representtive mp t >Provider Tools >Provider Representtive Mp or cll (option 1 for Network Development nd option 4 for Provider Reltions. You my lso emil network.development@bcbsl.com or provider.reltions@bcbsl.com. Blue Cross nd Blue Shield of Louisin incorported s Louisin Helth Service & Indemnity Compny 9

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$)''/?\Xck_$ bcbsnc.com Deductible options: $250, $500, $1,000 or $2,500 Deductible options $500, $1,000, $2,500, $3,500 or $5,000 D or (100% coinsurnce is not vilble on the $2,500 deductible option) coinsurnce plns: