BlueShield of Northeastern New York

1. BlueShield of Northeastern New York Chiropractic Program

2. Chiropractic Overview • Chiropractic Program • Provider Relations • HEALTHeNET/ ASK/ Provider Website • Quality Management • Wellness Benefit • Health Care Services • Future Projects • Questions

3. Changing Environment • The consumer’s role in health care decision making is expanding • Consumers will have more options for how, where, and from whom they purchase health insurance • Costs continue to rise and the quality of care needs to improve • Government regulations are dramatically changing

4. Beginning January 1, 2013: Chiropractic Program

5. Chiropractic Program Goals • Leverage claims data and quality measures to substantiate chiropractic services • Decrease spinal surgeries • Reduce pharmaceutical dependence • Pain medications and spinal injections • Inappropriate and unnecessary imaging for spinal issues • Optimize chiropractic provider network performance • Reduce administrative burden; less paperwork • More time with patients • Reduce over- and under-utilization • Increase outcomes and reduce risk • Align patients and providers • Support performance management programs

6. BlueShield of Northeastern New York Chiropractic Advisory Committee

7. Chiropractic Advisory Committee • Ensure continuing access to high quality, medically appropriate, evidence-based, cost-effective chiropractic care. • Maintain a consistent and clinically appropriate approach in the administration of chiropractic care, including development of clinical practice guidelines. • Develop clinically integrated programs and quality incentive programs. • Aid in the development of coverage criteria, review of coverage decisions, and technology assessments. • Review administrative rules pertaining to health care issues that may be related to the delivery of high quality chiropractic care.

8. Chiropractic Advisory Committee • Clinical Practice Guidelines • Chiropractic Treatment Request Form • Policies and Procedures • Medical procedures • Outcome-based pilot programs • Health Care Services programs

9. Chiropractic Committee Commitment • Members are appointed by BlueShield for a two-year term beginning with attendance at their first committee meeting and may be renewed for two additional two-year terms. • However, to ensure institutional memory of the committee, initial appointments may be extended to three- or four-year initial appointments. • After the initial two years of the committees’ existence, one-third of the members will rotate off the committee after two years, one-third after three years and one-third after four years. • If members do not volunteer to rotate off the committee, selection will occur via a random name selection process.

10. BlueShield of Northeastern New York Provider Relations

11. Provider Relations • The Provider Relations Specialist is your primary link with BlueShield. • Delegated by zip code or territory • Share information and analyze practice patterns in an effort to help you provide quality, cost-effective care • Our commitment to partnering with our participating providers is vital to providing quality coverage for our members.

12. Medical Management Model • Less cumbersome for the chiropractors. • A limited number of BlueShield ASO contracts will still be managed through the preauthorization process. • As a result, these members will have unlimited chiropractic coverage. • Members and providers will no longer have to complete the paperwork; therefore, access to care is easier with our model. • Furthermore, chiropractors will now have a direct line of communication with the health plan and the ability to share recommendations on quality programs and other initiatives.

13. Network Updates • Management of Services for chiropractors, massage therapists, and acupuncturists. • Open network enrollment: • January 1, 2013 • Previously, participating chiropractic providers: • Were dual contracted with Palladian network and the BlueShield network. • Will not need to do anything come January 1, 2013 because your participating provider agreement with BlueShield will automatically become effective.

14. Claim Submission • Dates of service December 31, 2012 and prior: • continue to submit to Palladian Health. • Dates of services January 1, 2013 and later: • submit to BlueShield for processing and reimbursement • Payor ID: 00800

15. Reimbursement/Fee Schedule for BlueShield • Increase in BlueShield fee schedule for initial and established office visits by 5 percent starting January 1, 2013 • All lines of business • Re-evaluation fee has been included • Allowed once every 3 months • Fee schedule is available on the provider website

16. Provider Credentialing Process (CAQH) • Providers can enroll into our health plan by filling out the Universal Credentialing Application with the Council for Affordable Quality Healthcare (CAQH) • Enter your CAQH Provider ID to enter or update your information • Authorize BlueShield to access your information electronically

17. Direct Communication • Provider Representatives • Provider Website • Provider Quarterly Newsletters • Yearly Provider Expo • Provider Customer Services • Chiropractic Advisory Committee

18. BlueShield of Northeastern New York Quality Management

19. Quality Management • Health Insurance Overview • InterQual Criteria • Chiropractic Authorization • Chiropractic Treatment Request Form/Flow Chart • Internal Processes • Quality Department • Fraud/Abuse

20. Health Care Plans and Systems • Managed Care Plans • Preferred Provider Organization (PPO) • Participants’ care must be provided by selected health care providers, but participants can go outside the network; co-insurance, high deductibles. • Exclusive Provider Organization (EPO) • Participants’ care must be provided by selected health care providers, but participants cannot go outside the network; they are completely responsible for payment. • Health Maintenance Organization (HMO) • Health care system assumes both the financial risk associated with providing services and responsibility for health care delivery in a particular geographic area; usually a fixed, pre-paid fee. • Point-of-Service (POS) • HMO/PPO ‘hybrid’: resembles HMO for in-network services, but services outside of the network are usually reimbursed in a manner similar to fee schedule. • Self-Insured Plans • Administrative Services Only (ASO) • Employer hires a third party to deliver administrative services such as claims processing and billing; employer bears the risk for claims.

21. Members Requiring Authorizations • ASO/Experience Rated Groups (Self-Funded) • Fastest growing types of employee benefit arrangements • Employers are responsible for directly funding all employee claims • Employers pay a fixed fee for administrative services like claim payment and management reporting • An insurance company provides those administrative services, but doesn’t collect any premiums where no insurance risk has been underwritten

22. Chiropractic Visit Restrictions • Three Major Limitations: • Medical Necessity Prior Authorization Requirement • Can vary from first visit to the twentieth visit • Maximum dollar limit, ex: $200 • Maximum visit limit, ex: 20

23. Clinical Practice Guidelines • InterQual Chiropractic Criteria • Created by actively practicing chiropractors across the country. • Promotes evidence-based standards of care. • Accepted by: • Chiropractic Advisory Committee • Quality Management Committee • Available on the Provider Website

24. Medical Review:Chiropractic Treatment Request (CTR) • Provider Office • Checks patient contractual agreement • If no limits: treat patient • If limits: determine allowable visits • Complete the CTR form before contractual visits have been exhausted • For example: • If five visits are allowed without medical necessity, complete CTR form after the fourth visit • Fax completed forms to BlueShield at 1-716-887-7913 • Provider and member will be notified of decision within three days via: • mail • phone call • If additional visits are required, submit additional CTR forms

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27. Chiropractic Treatment Request • Step 1: • Checked by staff: • Eligible member • If required • Complete • Step 2: • Checked by RN: • CTR reviewed against InterQual Criteria • Additional visits given • If unable to make a determination • Step 3: • Checked by chiropractor: • Combination of InterQual Criteria and clinical judgment

29. Provider Expectations • Self Governance • Maintain quality medical records • Comply with HIPAA standards • Practice Guidelines • Apply appropriate evidence-based care to members • Ensure BlueShield-accepted clinical guidelines are used • Comply with regulatory agencies

30. BlueShield of Northeastern New York Wellness Benefit

31. The Wellness Card • Available with the Aqua plan, Wellness Benefit (formerly Lifestyle Rider), and Healthy Balance, effective January 1, 2013. • All subscribers will receive a Visa card to be used with a nationwide network of health and wellness retailers based on merchant type and/or merchant category. • Fitness centers • Massage therapy • Chiropractic visits • Health food stores • And many more! • All transactions are handled through Visa and processed through our vendor, Discovery Benefits.

32. The Wellness Card • Lifestyle Rider: Effective January 1, 2013 the Lifestyle Benefit will be referred to as the Wellness Benefit. • A wellness card will be provided to subscribers of the Aqua plan, Wellness benefit, and Healthy Balance.

33. Senior Fitness Benefit • The BlueShield network will be partnering with SilverSneakers, effective January 1, 2013. • If you are not currently part of the SilverSneakers network but would like to be, you can submit a request to begin the application process online at silversneakers.com. • If you are already a SilverSneakers provider, no further action is required.

34. BlueShield of Northeastern New York HEALTHeNET Web Application PCI HELP DESK 1-877-895-4724 HOURS OF OPERATION: 7 a.m. - 7 p.m. Monday-Friday

35. EPRO Provider File Updates Security: One User ID and Password EPRO Claims Adjustment Requests HIPAA Membership & Eligibility Transaction HEALTHeNET 30,000+ users EPRO Future??? HIPAA Referrals Transaction HIPAA Claims Status Transaction Administrative Transactions:One Stop Shopping…

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