1 / 91

PROVIDER RELATIONS SEMINAR APRIL 2007

PROVIDER RELATIONS SEMINAR APRIL 2007. Seminar Agenda. Welcome – Jeanne Wisnewski, Director Provider Relations First Priority Life Insurance Company (FPLIC) – Overview and Product Transition Billing Information – BCNEPA, FPH and FPLIC NaviNet Enhancements

shaquana
Télécharger la présentation

PROVIDER RELATIONS SEMINAR APRIL 2007

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PROVIDER RELATIONS SEMINAR APRIL 2007

  2. Seminar Agenda • Welcome – Jeanne Wisnewski, Director Provider Relations • First Priority Life Insurance Company (FPLIC) – Overview and Product Transition • Billing Information – BCNEPA, FPH and FPLIC • NaviNet Enhancements • “Blue” Updates – BCNEPA, FPH, FPLIC and HMBS • Medicare Advantage PPO (Freedom Blue)

  3. First Priority Life Insurance Company FPLIC PROVIDER TRAINING APRIL 2007

  4. FPLIC Agenda • Overview of company, product and networks • Network recruitment • Service Authorization Process • Claim Submission/Adjustments/NaviMedix • Remittance Advice/payments • Member Services • Questions – All

  5. FPLIC Handouts • Overall Precert grid for all FPLIC Products • Benefit Grids • Remittance Advice/EOBs • Key Information – January and April 2007 Provider Bulletins

  6. FPLIC Background First Priority Health Life Insurance Company (FPLIC): • Branded • BCNEPA/Highmark ownership • BCNEPA is the managing partner • Replacing ACII product – formal withdrawal of this product from the market place – PID notified • Transition of Traditional/Major Medical product – May 2007

  7. FPLICService Area & Products • Geographical Service Area – 13 counties only Products: • BlueCare PPO: - QFG • Market entry May 2007 • BlueCare PPO QHDHP: - QFG • Group high deductible plan • Market entry January 2007 • Designed for a Health Savings Account (HSA) – BUT FPLIC will NOT be managing – up to employer or individuals to decide if necessary and implement with financial institution.

  8. FPLIC Products Cont’d Products: • BlueCare Direct: - QFD • PPO non group • Medically Underwritten • Individual Contracts • For Uninsured • Market entry April 2007 • BlueCare PPO Individual Conversion: - QFC • PPO non group • Must be in group for 3 months to qualify for this product

  9. FPLIC Products Cont’d Products: • BlueCare Individual Conversion: - QFC • PPO non group • Alpha prefix QFC • Must be in group for 3 months to qualify for this product • Not approved by PID at this time • BlueCare Traditional: - QFT • Groupproduct • Transition beginning with May 1, 2007 renewals • Continued transition through May 2008 • Not a PPO, but a traditional product

  10. FPLIC Products Cont’d Products: • BlueCare Comprehensive: - QFM • Groupproduct • Transition beginning with May 1, 2007 renewals • Continued transition through May 2008 • Not a PPO, but a traditional product

  11. FPLIC Network Facilities: • Existing BlueCross facilities with some extensions to lab and radiology providers Professionals: • Foundation is HMO network + Geisinger and other professionals CRNA, CRNPs, primary/specialty physicians not currently in the HMO network * Executed Traditional/Major Medical contracts Special Circumstances: • Mental Health facilities – foundation is HMO Network • Independent Radiology centers – foundation is HMO Network with some extensions • Sleep Centers – foundations is HMO Network

  12. FPLIC Network Cont’d Out-of-AreaBlueCard: • FPLIC members OOA use Highmark Premiere Blue Network & any Blue facility network • If OOA and directly contract with FPH or FPLIC, would submit as previously instructed Directory: • NO hardcopies • All online via BCNEPA Corporate website, www.bcnepa.com

  13. FPLIC Network Recruitment & Applications Network Recruitment/Applications: • HMO comparison report to Premiere Blue – fallout→ sent applications/agreement Requests for Applications: • Will use the same process as always

  14. FPLIC Prior Authorization Prior authorization may be called in, faxed or submitted via BCNEPA NaviNet: Utilization Management Department Blue Cross of NEPA 8:00 a.m. to 4:00 p.m. Monday through Friday BlueCare Traditional/1-800-638-0505 BlueCare PPO/1-866-262-5623 Fax Number 570-200-6788 Note: FPLICdoesnot require initial approvals (Blue Cross Admissions) For in-patient admissions, SNF, home health or hospice claims.

  15. FPLIC Prior Authorization Cont’d Criteria: - BC Utilization Management Department bases its decision on specific criteria to determine medical necessity. - Criteria is available to BlueCare providers upon request. - Criteria may be requested by contacting or faxing the BC Utilization Management Department with the following information: - Member Name - BlueCare identification number - Date(s) of service -Date(s) of denial - Facility where services were rendered Blue Cross of NEPA/BlueCare 19 N. Main Street Wilkes-Barre, PA 18711-0302 Phone Number: 1-866-262-5623 Fax Number: 570-200-6788

  16. FPLIC Prior Authorization Cont’d Process: • Business hours/non-business hours • Prior Authorization Notification Letter • Prior Authorization Appeal – If the member or attending physician disagrees with the Utilization Management Department’s determination of medical necessity, the attending physician may appeal the determination by: • Medical Director - 1-800-462-0900 within 24 hours of the denial • An appeal may also be requested in writing with supporting medical records within 60 days of the denial letter, and submitted to:Regulatory Compliance Department BCNEPA 19 N. Main Street Wilkes-Barre, PA 18711-0302

  17. FPLIC Prior Authorization Cont’d In-Area Admissions - Prior Authorization (DRG Facilities): Note:The FOCUS Prior Authorization list for this product line is the same as the current BC FOCUS Prior Authorization list. The only additional services are abdominoplasty/panniculectomy (15830 CPT and 86.83 ICD-9) and transplants. • Focus Prior Authorization requires that targeted diagnosis and/or procedures • Focus Prior Authorization Diagnosis/Procedure List (requires prior authorization only if patient is admitted as an inpatient). • Prior Authorization is required only for the specific medical/surgical procedures outlined in your handout. Prior authorization approvals are valid for up to 60 days from initial request. • The hospital shall be responsible for furnishing to BC’s Prior Authorization Department any required medical information relative to the prior authorization process.

  18. FPLIC Prior Authorization Cont’d In-Area Admissions – Prior Authorization (DRG Facilities) Con’t: • Denial of services may occur. Please refer to your BlueCare Provider Policy and Procedure Manual, Admission/Discharge – Section E, Page 3, under Responsibility of Participating Hospital. • In the event that one of these situations occur, the participating hospital may not charge either Blue Cross or the member for services rendered with respect to such admission.

  19. FPLIC Prior Authorization Cont’d Acute Inpatient Services: • Elective Admissions • Emergency/Urgent • Short Procedure Unit (SPU) – only complications requiring inpatient stay need pre-admission certification.

  20. Behavioral Health Care Services - • All inpatient and partial hospitalization psychiatric and chemical dependency admissions require pre-admission certification. • All out-of-area inpatient admissions regardless of group or individual contract require pre-admission certification. • Contact: Regional Referral Center: 1-800-577-3742 FPLIC Prior Authorization Cont’d Requires Prior Authorization • Skilled Nursing Facility • Home Health Services • Inpatient Acute Physical Rehabilitation Hospitalization Note: As of January 1, 2006, providers who are NaviNet enabled MUST submit the initial prior authorization request for home health or inpatient rehabilitation services via NaviNet. • Home Infusion Services – Certain home infusion benefits require prior authorization by the Blue Cross Pharmacy Management Department. • Phone Number – 1-800-722-4062 • Fax Number – 570-200-6870 • Behavioral Health Care Services - • All inpatient and partial hospitalization psychiatric and chemical dependency admissions require prior authorization. • All out-of-area inpatient admissions regardless of group or individual contract require prior authorization. Contact: Regional Referral Center: 1-800-577-3742

  21. FPLIC Prior Authorization Cont’d Out of Area Admissions: • ALL admissions (elective, emergency/urgent and inpatient stay due to SPU complications) to a BlueCare non-network/out-of-area hospital will require prior authorization. • Maternity Admissions – Prior authorization is not required for maternity admissions for BlueCare members either in or out of area. • If the baby is detained after the mother is discharged, prior authorization is required for out of area only.

  22. FPLIC Claims Review Electronic Claims • Electronic claims will continue to be sent to Blue Cross of NEPA: • Through their vendor’s EDI capability, E-Premis, NaviNet, EMDEON, etc. • Both institutional and professional claims are submitted to Blue Cross of NEPA for FPLIC products. • NPI requirements have been and will continue to be sent to the providers via our ‘Provider Bulletins’. • Claims will then be re-enveloped by BCNEPA’s IT Dept. and sent to Highmark • Processed in the OSCAR system. • The UB92 system will not be utilized for FPLIC. • Blue Cross Admission Approvals will NOT be required for inpatient, SNF, home health or hospice claims for FPLIC Products. • Providers can register online for electronic billing via our corporate website www.bcnepa.com. Click on the Provider Tab and EDI registration appears on the left hand side of the screen. • Highmark’s Oscar system will adjudicate claims. Therefore, HBS billing guidelines are to be followed.

  23. FPLIC Claims Review Cont’d Acceptance/Rejection Reports: Facility - There will be a separate A/R report generated on NaviNet for electronic billing submitters, and the title will be “BlueCare Acceptance/Rejection”. - The error codes will be in a HIPAA format. • It is anticipated to add a description of the code to the reports in the future. Professional - Depends on the clearinghouse; for example, EMDEON (formerly WebMD) has their own proprietary report. - NDC uses the BCNEPA report; - McKesson has no report at this time; Direct connect providers will use NaviMedix or there is no report (there are no professionals billing us direct at this time).

  24. FPLIC Claims ReviewCont’d Hardcopy Claims Mail to: FPLIC/BlueCare P.O. Box 890179 Camp Hill, PA 17089-0179 Claims will be processed on Highmark’s system. Note: NPI requirements have been and will continue to be sent to the providers via BCNEPA Provider Bulletin and Highmark’s PRN Plan Code: All Products will utilize Plan Code 274.

  25. FPLIC Claims Review Cont’d Adjustments: Institutional providers that bill on the UB92/UB04 billing form have two (2) options: Option 1: They can utilize the Blue Cross adjustment form that has been modified with a box titled, “First Priority Life Insurance Company” to accommodate these adjustment requests. Highmark strongly recommends electronic submission. Option 2: They can electronically submit bill types XX5 (late chgs.), XX7 (adj.), XX8 (cx.) Note: Professional providers can submit a corrected hardcopy claim as they do today. Caution: UB92 period ends 05.23.07 – NEW UB04 format is to be used for DOS 05.23.07 forward

  26. FPLIC Claims Review Cont’d Medical Policy and Medical Record Requests: • BCNEPA’s medical policies will be applied to claims, however, if there is a “gap” for a specific service, we will then revert to Highmark’s policies. • Medical record requests will be system generated and sent to the provider from Highmark. • The letter will include an address where records should be sent. • Claims will pend for 14 days and if no records rec’d. in that time frame, the claim will be rejected.

  27. FPLIC Claims ReviewCont’d Provider Claim Appeals: Institutional provider appeals should be submitted in writing to: Blue Cross of NEPA Regional Manager, Provider Relations 19 N. Main Street Wilkes-Barre, PA 18711 Professional provider appeals should be submitted in writing to: Blue Cross of NEPA Medical Policy Dept. 19 N. Main Street Wilkes-Barre, PA 18711

  28. FPLIC Claims ReviewCont’d Blue Card Program: Providers will submit as they do today, to their local Plan. Institutional to BCNEPA and professional to Highmark. NaviNet: Both professional (CMS 1500) and institutional claims can be entered via NaviNet. • FPLIC line of business has been added to the dropdowns on the survey screen of the UB92/UB04 submission transaction. • FPLIC line of business will also appear on the patient search screens to indicate a FPLIC member. * Note: As of 03.31.07 – NPIs will appear and will only appear after 05.23.07 – NO NPI – NO NAVINET SUBMISSION!

  29. FPLIC Payment Facility Payment: • Remittance Advice • All inpatient claims by patient last name • All outpatient claims by patient last name • If a provider has electronic remittance advice, “a separate ERA will be generated in NaviNet and titled “BlueCare PPO institutional”, or “BlueCare PPO Professional”. • If the provider currently has Blue Cross EFT/ACH, details are in progress to allow facilities to have FPLIC EFT. Target Date - May 2007. • If provider receives a check, all checks for FPLIC products will be a separate paper check. • Schedule • Mailing date of checks and RA’s to be determined

  30. FPLIC Payment Cont’d Payment Mechanism: • Concurrent processing for Traditional/Major Medical only…services are adjudicated under correct line of business • Provider receives one payment and only one remittance advice/EOB. Facility Payment: • Note: New BlueCross or Highmark Electronic Funds Transfer (EFT) Requests take 3-5 weeks from application to activation. EFT Provider Contact: • Karen Klimchak – 570-200-4672

  31. FPLIC Payment Cont’d Professional Payment: • Explanation of Benefits (EOB) • Sorted by patient’s last nameNote:Will eventually be sorted by product, then by patient’s last name. • Schedule • Mailing date of checks and EOB’s to be determined. • Payment Methods • Check if currently receiving • ACH/EFT target May 2007 ** If have ACH through Highmark currently! • It is anticipated to be offered later in 2007 to remaining network.

  32. FPLIC Payment Issues Payment Open Issues: • Whose business rules are followed? • Highmark providers and BCNEPA facilities may receive both an 835 and hard copy. • FPH providers may receive one or the other – not both.

  33. FPLICCustomer Services BlueCare Service Representatives (formerly Customer Service Representatives) Member Customer Service – 1-888-827-7117 Blue Care Trad/Maj Med 1-866-262-5635  Blue Care PPO and Blue CareComprehensive • Help members understand their benefits and exclusions, • Answer eligibility and claims questions, • Assist members in filing formal complaints and grievances. Provider Customer Service – 1-866-262-5635 • Assist providers with claims questions, • Assist providers with member eligibility and benefit questions, • Available through NaviNet SM. Hours • Monday through Friday 8:00A.M. to 5:00 P.M.

  34. FPLIC ID CARDS

  35. QUESTIONS Questions

  36. Billing Information AGENDA • NPI and Taxonomy Code • NUCC-1500 Claim Form • UB04 Claim Form

  37. NPI at a Glance Required as a result of HIPAA Regulation • Individuals and groups must apply • http://nppes.cms.hhs.gov • Complete on-line application • Download and print application OR • Call 1-800-465-3203 to request an application

  38. NPI (cont’d) • Register your NPI with all payers • Identify the payers’ format requirements • Contact your practice management software vendor to initiate any necessary format changes • NPI required on electronic claims 5/23/07

  39. Taxonomy Code • Required as a result of HIPAA Regulation • Must be reported on the claim • Must match confirmation letter (Taxonomy codes are assigned by payer based on credentialing – FPH may differ from Highmark) For a list of valid taxonomy codes: http://www.wpc-edi.com/codes/taxonomy

  40. Claim Submission • Paper Claims • Proper alignment • Data in the boundaries of the boxes • Legibility • Right information in the right fields • All required fields completed • NUCC-1500 Form required 6/1/07

  41. Claim Submission - Paper • Only 6 service lines (shaded lines above the service lines are for supplemental information only) • Regularly change your print ribbon/print cartridge to ensure the print is dark enough to be read by scanner • Avoid using special characters-i.e.: $ - / • Use “X” for yes/no blocks • Do not attach superbills • Consider changing to electronic submission

  42. Claim Submission • Electronic Claims • Right information in the right fields • Review acceptance/rejection reports • Correct errors and resubmit electronically Please, do not drop rejected electronic claims to paper • Highmark accepts secondary claims and claims with paper attachments electronically. Information is available at: www.highmark.com/edi

  43. Overview of Form Changes • NUCC-1500 • UB-04

  44. NUCC -1500

  45. NUCC-1500 Field 24 (i) – describes what type of number you’re reporting in field 24(j): On the shaded line: • Use “ZZ” if you report the provider’s taxonomy code • Use “1G” if you report the provider’s UPIN # • Use “G2” if you report the provider’s FPH # • Use “1B” if you report the provider’s Highmark / FPLIC # OR In the unshaded area, note that 24(i) is pre-filled with “NPI” Leave field 24(i) blank if you are reporting the provider’s NPI #

  46. NUCC-1500 Field 24 (j) – the identifying number of the individual rendering the service(s) On the shaded line: Enter the individual’s taxonomy code, UPIN # or their payer assigned insurance provider ID# based on the reported qualifier. Do not insert any spaces between shaded fields 24(i) and 24(j) OR On the unshaded line: Report only the provider’s NPI#

  47. NUCC-1500 Field 32(a) Enter the NPI# of the facility where the services were performed, followed by the associated taxonomy code in Field 32(b) Remember to include the “ZZ” qualifier in field 32(b) followed immediately by the taxonomy code.

  48. NUCC-1500 If the facility NPI# is not reported in 32(a), then in Field 32(b), use the same logic applied to the shaded fields in 24(i) and 24(j) Report the qualifier first (1G if you’re using the UPIN,G2 for the FPH #, or 1B for the HMBS#) and the appropriate identification number For example, G2 means I’m using the FPH provider #, and 800053 is the actual provider number. In field 32(b), I would report: G2800053

  49. NUCC-1500 For First Priority Health Claims: Fields 33(a) and 33(b): 33(a) – Enter the performing provider’s NPI# (Individual NPI only – not the group’s NPI) 33(b) – Enter “ZZ” followed immediately by the performing provider’s taxonomy code

  50. NUCC-1500 For Highmark Blue Shield and FPLIC Claims: Fields 33(a) and 33(b) 33(a) – Enter either the performing provider’s NPI# (if a solo practice) OR the group’sNPI# if applicable 33(b) – Enter “ZZ” followed immediately (no spaces) by the taxonomy code of the entity reported in field 33(a). If no NPI, report the qualifier first (1G,G2,1B) and the appropriate identification number in 33(b).

More Related