Precertification requirements for FEP members for BRCA testing and outpatient services

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1 INSIDE THIS EDITION Reminder: Delinquent payment indicator on NaviNet for APTC members Learn about a field that informs providers when APTC members are delinquent in paying their premiums Providers financially responsible for preapproval/precertification of inpatient facility services for Understand provider responsibility for preapproval of inpatient facility services for Expediting medical record requests from the Host Plan Read about the importance of completing medical record requests from a Host Plan in a timely way Use the Medical Policy/ Precertification Router for Find coverage requirements for through NaviNet Ask to complete the COB Questionnaire with other registration forms Have complete the COB Questionnaire before receiving services WINTER 2015 Precertification requirements for FEP members for BRCA testing and outpatient services Effective January 1, 2015, BRCA (breast cancer gene) testing requires precertification for members who have coverage under the Federal Employee Program (FEP). As previously communicated, the services listed below also now require precertification: outpatient intensity-modulated radiation therapy (IMRT), except related to the treatment of head, neck, anal canal, anal, breast, or prostate cancer (Note: Brain cancer is not considered a form of head or neck cancer; therefore, precertification is required for IMRT treatment of brain cancer); outpatient surgery for morbid obesity (refer to the Service Benefit Plan summary at benefit-plans-brochures-and-forms/#tab-brochures for specific pre-surgical criteria that must be met); outpatient surgical correction of congenital anomalies; outpatient surgery needed to correct accidental injuries to the jaw, cheeks, lips, tongue, and roof or floor of mouth. Services must meet the requirements listed in the applicable FEP medical policies, which are available on the FEP website at Scroll to the bottom of the page and select Medical Policies. To obtain precertification for services for BRCA testing or outpatient services for FEP members, call Highmark Blue Shield, an independent company, at As a reminder, precertification requests for inpatient and hospice services for FEP members will continue to be performed by Independence. Failure to obtain precertification will result in a retrospective review to determine compliance with FEP medical policies. Should services be denied for lack of medical necessity, reimbursement will not be made and the member may not be billed. v

2 Reminder: Delinquent payment indicator on NaviNet for APTC members The Advanced Premium Tax Credit (APTC) is part of the Patient Protection and Affordable Care Act, also known as Health Care Reform. The APTC helps qualifying individuals and families obtain health insurance by reducing monthly premiums. Health Care Reform mandates a three-month (i.e., 90-day) grace period for individual APTC members who are delinquent in paying their portion of the premiums. Under the mandate, insurers are required to pay medical claims received during the first 30 days of the grace period, but they may pend medical claims for services rendered to those members and their eligible dependents during the second and third months of the grace period. If payment is not received by the end of the grace period, the pended claims will be denied and the member s policy will be terminated. Delinquent payment indicator A field called APTC displays within the Eligibility and Benefits Details screen on the NaviNet web portal to show providers when a patient is in the grace period and to provide a status of the member s claims. When an APTC member is delinquent on his or her monthly insurance premiums, the APTC member indicator and current status will display on the Eligibility and Benefits Details screen. The current status includes (1) the number of months that the member is delinquent, (2) whether the insurance company will pay, suspend, or deny the member s medical claims. Note: The APTC field will only display when an APTC member is in a delinquency status. If an APTC member s claim is suspended due to a delinquent payment, the corresponding code and reason will also appear within the claim line in the Claims Status Inquiry transaction. Select Additional Details for an explanation of why the claim is not yet finalized. For more information To help you navigate information for APTC members who have a delinquent payment, a user guide is available in the NaviNet Transaction Changes section of our Business Transformation site at If you have any questions about NaviNet transactions, please call the ebusiness Hotline at v 2

3 Providers financially responsible for preapproval/precertification of inpatient facility services for Participating providers are financially responsible for obtaining preapproval/ precertification for inpatient facility services for, and are held harmless for these services. While most providers currently obtain preapproval/precertification for inpatient facility services, this new requirement moved financial responsibility for lack of preapproval/precertification from the member to the provider. Failure to obtain preapproval/precertification for inpatient facility services for will result in a denied claim. To avoid claim denials, it is important to preapprove/precertify the inpatient stay and check that additional days are authorized before an out-of-area member is discharged. Providers must notify the member s Home Plan of the following: within 48 hours, notify of any changes to the original pre-service review; within 72 hours, notify of emergency/urgent pre-service review. Inpatient stay extensions for DRG/case rate facilities In diagnosis related group (DRG)/case rate situations, when the length of an inpatient stay extends beyond the preapproved/precertified length of stay, any additional days should be approved by the last day of the originally approved days. For example, if five days are approved by the Home Plan and the patient has not been discharged by the fifth day, the provider should contact the Home Plan and ask to have the authorization updated. Please ensure that you seek approval of additional days to avoid payment issues. Denied days within an approved inpatient stay for non-drg/ case rate facilities In non-drg/case rate situations, if there are denied days within an approved inpatient stay, the provider will be financially liable for the denied days and the member will be held harmless. Get preapproval/precertification electronically Independence offers Electronic Provider Access (EPA) through the NaviNet web portal to access the provider portal of an out-of-area member s Home Plan and conduct electronic pre-service reviews. Please note that providers may still need to call the member s Home Plan to request preapproval/ precertification if the Home Plan does not offer electronic pre-service review. The Pre-Service Review for Out-of-Area Members transaction is available under the Blue Exchange Out of Area option in the menu of plan transactions. A user guide for this transaction is available in the NaviNet Transaction Changes section of our Business Transformation site at pnc/businesstransformation. If you have any questions regarding NaviNet transaction changes, call the ebusiness Hotline at Note: Providers can also get preapproval/precertification for out-of-area members by calling the BlueCard Eligibility line at BLUE and asking to be transferred to the utilization review area. v Expediting medical record requests from the Host Plan When a Host Plan receives a request for medical records from a Home Plan, it is very important that the records be sent in a timely manner to ensure that the provider is reimbursed and the services rendered by the out-of-area member are covered appropriately. To expedite the handling for Host Plan medical record requests, please adhere to the following tips and guidelines: Include a copy of the request letter with the medical records. Submit medical records by fax or for the quickest processing. Only send the medical records that have been requested. Note: Independence cannot forward unsolicited medical records to another plan. Host Plan medical records can be sent in the following ways: Fax. Securely fax medical records to medical records to Mail. If you do not have access to fax or , send medical records on a CD or in hardcopy to: Host Medical Records Department 1901 Market Street SG1 Philadelphia, PA Note: This information does not apply to medical record requests directly from a Home Plan or to appeals. v Reminder: Appeals sent should clearly indicate the patient s name, member ID number (including alpha prefix), and claim number, when applicable. 3

4 Use the Medical Policy/Precertification Router for Understanding a benefit plan s precertification requirements is crucial for both members and providers. Because providers typically obtain precertification on behalf of members, it is important that they have easy access to information about these requirements. In the BlueCard environment, medical policy and precertification requirements are dictated by the Home Plan. Local providers may be unaware when the Home Plan s medical policy or precertification requirements are different from the local Plan s requirements. Use the Medical Policy/Precertification Router Using the Medical Policy/Precertification Router on the NaviNet web portal, you will be routed to the Home Plan s website that contains medical policies and general precertification requirements. This transition happens seamlessly based on the alpha prefix of the out-of-area member s Plan, and it gives providers easy access to medical policy and precertification requirements. To view medical policy and precertification requirements for out-of-area Blue members, select Medical Policy/PreCert Inquiry from the BlueExchange Out of Area option in the menu of plan transactions. Then to conduct a search, select Medical Policy or Pre-Certification from the drop-down menu under Type of Inquiry. Simply enter the alpha prefix noted on the member s ID card and select Submit. The information that will be displayed is provided by the member s Home Plan. If you have any questions regarding the information, please contact the member s Home Plan. v 4

5 Dependent(s) listed on the other insurance Policyholder s Employer INSIDE IPP WINTER 2015 Additional resources For BlueCard facility claims, call ASK-BLUE ( ). For questions about BlueCard eligibility, call the BlueCard Eligibility line at BLUE ( ). Inside IPP is a publication of Independence Blue Cross and its affiliates (Independence). Suggestions are welcome. Contact information Provider Communications Independence Blue Cross 1901 Market Street, 27th floor Philadelphia, PA provider_communications@ibx.com NaviNet is a registered trademark of NaviNet, Inc., an independent company. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association. Ask to complete the COB Questionnaire with other registration forms Coordination of benefits (COB) refers to how the Blue System ensures that members receive full benefits and prevents double payment for services when he or she has coverage from two or more sources. When providing services to out-of-area* Blue members, it is important that they complete the COB Questionnaire for the following reasons: streamlined claims processing; expedited payment to providers; reduction in the number of denials related to COB; ability for employer groups to finalize out-of-area claims for their employees. Instructions for completing the questionnaire Out-of-area Blue members should complete the COB Questionnaire with other registration forms. The questionnaire is available on our website at /claims_and_billing/bluecard. html or through the NaviNet web portal by selecting BlueCard COB Questionnaire from the BlueExchange Out of Area option in the menu of plan transactions. Office staff should complete the first two fields of the questionnaire: provider name and NPI. Then, the out-of-area member should complete the remaining sections of the questionnaire before services are rendered. Please immediately process the completed questionnaire by faxing it to or by mailing it to the address printed on the first page of the questionnaire. If you have any questions about this important process, contact your Network Coordinator. Note: The COB Questionnaire should not be used for local Independence members or Federal Employee Program members. v *Out-of-area members are members of other Blue Cross and Blue Shield plans who travel or live in the Independence five-county service area, which includes Philadelphia, Bucks, Montgomery, Chester, and Delaware counties. Coordination of Benefits Questionnaire: Out of Area Members Provider: After the policy holder has completed and signed, please forward this form to your local Blue Cross and/or Blue Shield Plan immediately. Do not hold to submit with the claim. Please fax or mail this form to the following: PO Box Harrisburg, PA Fax: Member: Your Blue Cross and/or Blue Shield contract may contain a Coordination of Benefits (COB) provision. Your Plan depends upon your help in order to process your claims correctly and appreciates your prompt and accurate reply. If any of the information below changes, please contact your Blue Cross and/or Blue Shield Plan immediately. Provider Name NPI (Give Tax ID if No NPI Number) Policyholder Last Name Policyholder First Name Group Number Member ID Number with Three Letter Prefix (Must Include Plan Alpha Prefix) Section A Other Insurance If this does not apply, check No and skip to Section B Are you or any other member of this Blue Cross Blue Shield policy covered by another medical or dental insurance policy, any other Blue Cross Blue Shield policy or Medicare? No If No, please complete Section D, sign, date and return this questionnaire to us, indicating No other insurance. Yes If Yes, please complete all the fields below that pertain to the member(s) that has the other coverage. Mark those that apply: Other Health Insurance Other Dental Insurance What type of policy is this? Group Individual Policy Student Policy Medicare Supplemental Other Insurance Carrier s Name Address Address State Zip Phone Number Other Insurance Policyholder s Name Policyholder s Date of Birth ID Number Effective Date of Other Insurance If Cancelled, Cancellation Date Is the policy holder: Actively working for the group Inactive Retired, retirement date: On COBRA, which began: Address City State Zip Phone Number 5