2016 Benefit Update Meeting - South Carolina Blues · 2016 Benefit Update Meeting ... Teosha Harrison • Affordable Care Act (ACA) and Exchanges ... • Maternity benefits vary by

2016 Benefit Update Meeting

Presented by Provider Relations & Education

#2016providerworkshop

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• Welcome & Introductions Teosha Harrison

• Affordable Care Act (ACA) and Exchanges

• Federal Employee Program (FEP)

• State Health Plan • Upstate 1 Networks • Preferred Blue® (PPO) • BlueChoice® HealthPlan of

South Carolina • BlueChoice HealthPlan

Medicaid

• BlueCard® Program • Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • International Classification of

Diseasaes-10 (ICD-10) • Provider Credentialing • Additional Provider Reminders • Closing

Agenda

Note: Contents are subject to change and are not a guarantee of payment.

Avalon is an independent company that provides benefit management services on behalf of BlueCross.

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Welcome & Introductions

Our Mission is to serve as liaisons between BlueCross, BlueChoice® and the health care community to promote positive relationships through continued education and

problem resolution.

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Welcome & Introductions Brian Butler

Senior Director

Teosha Harrison Manager, BlueCross & BlueChoice

Jada Addison Provider Advocate

Elizabeth Duvall Provider Advocate

Shamia Gadsden Provider Advocate

Ashlie Graves Provider Advocate

Mary Ann Shipley Provider Advocate

Contessa Struckman Provider Advocate

Sandy Sullivan Provider Advocate

Bunny Thomas Provider Advocate

Sharman Williams Provider Advocate

Jamie Self Provider Relations Assistant

Shay Looker Manager, BlueChoice Medicaid

Tom Ingram Provider Representative

Jon Keith Provider Representative

Donese Pinckney Provider Representative

Donna Thompson Provider Representative

The Provider Relations teams are here for you! Contact your county’s designated consultant

for training requests.

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Provider Contracting Tiesha Williams [email protected] 803.264.4010 Ancillary and Hospital Contracting Scott Crisler [email protected] 803.264.4009

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Welcome & Introductions Brian Butler

Sr. Director, BlueCross

Brenda Bethel Director

Mark Austin Manager

Marcelette Pearson Manager

Tammy Ross Manager

Tammy Stephens Director, BlueChoice

Jameela Jones Manager

James Stone Manager

The Provider Services teams are essential to the service we give to our providers.

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Tony Salvati and Michele DeCaprio Kathy Wade and Kerri Fritsch

Natalie Johnston Ansley Lee, Donyale Springs,

Pamela Trapp

Representatives from

National Imaging Associates (NIA) Avalon Healthcare Solutions Companion Benefit Alternatives (CBA) Patient Center Medical Home

Disease Management Corporate Quality BlueChoice HealthPlan Medicaid

2016 Benefit Update Meeting Acknowledgements

NIA is an independent company that provides utilization management services on behalf of BlueCross.

CBA is a separate company that manages behavioral health and substance abuse benefits for BlueCross

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Welcome & Introductions • Webinars: We offer online presentations of various education topics

each month. • Newsletters and Bulletins: BlueNews for Providers is available monthly

and we post provider updates in the Provider News section of both websites.

• Regional Workshops: Workshops on corporate initiatives are presented throughout the year.

• Direct Contact and Support: You may reach our internal and external advocates by calling 803-264-4730 or by email at [email protected].

• Reports: monthly, and upon request, providers receive Gaps in Care (GIC) reports, Provider Report Cards, and even pending claim reports.

• On-site Visits: Upon request we will visit your office to train your staff on our business processes.

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Agenda • Welcome & Introductions • ACA and Exchanges

Bunny Thomas • Federal Employee Program

(FEP) • State Health Plan • Upstate 1 Networks • Preferred Blue® (PPO) • BlueChoice® HealthPlan of


Medicaid

• BlueCard® Program • Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider Reminders • Closing

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Affordable Care Act (ACA) and Exchanges

Essential Health Benefits Benefits include services in 10 categories:

1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use

disorder services, including behavioral health treatment

6. Prescription drugs 7. Habilitative and rehabilitative

services and devices 8. Laboratory services 9. Preventive and wellness services

and chronic disease management 10.Pediatric services, including vision

care

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ACA and Exchanges For more Information on ACA Benefits • We have three medical policies that

address ACA preventive benefits. — www.SouthCarolinaBlues.com or

www.BlueChoiceSC.com

• You can also refer to our Preventive Care Guide for details about applicable ACA preventive benefits.

• We will continue to add or update information as we get new regulations or further guidance from the federal government.

http://www.southcarolinablues.com/

http://www.bluechoicesc.com/

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ACA and Exchanges BlueCross Exchange Plans: Small Group Plans BlueCross offers plans to businesses with two to 50 employees. These plans use the preferred provider organization (PPO) Network.

Alpha Prefixes ZCV Small Group Private

ZCR Small Group FFM

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ACA and Exchanges BlueCross Exchange Plans: Individual Plans BlueEssentialsSM is a line of individual plans BlueCross offers. The network name indicates that the Blue Essentials Network is being used. This network is unique to these plans.

Alpha Prefixes ZCU Individual Private ZCF Individual FFM ZCQ Individual FFM (Multi-state Plan)

Members do not have out-of-network benefits.

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ACA and Exchanges 2016 BlueEssentials

Benefit Examples Gold 2 Silver 4 Bronze 1

DEDUCTIBLES

Individual Deductible $800 $2,200 $6,000

Family Deductible $1,600 $4,400 $12,000

SERVICES

Office Visits $15 primary care physician (PCP), $40 specialist $30 PCP, $50 specialist

$80 PCP on first four visits then deductible and 40% coinsurance

$125 specialist

Inpatient Facility Services Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 40% coinsurance

Outpatient Facility Services Deductible then 30% coinsurance Deductible then 30% coinsurance Deductible then 40% coinsurance

Emergency Room $300 copay, then deductible, then 30% coinsurance

$300 copay, then deductible, then 30% coinsurance Deductible then 40% coinsurance

Mental Health Deductible then 30% coinsurance Not applicable Deductible then 40% coinsurance

COINSURANCE MAXIMUM

Individual-Network $4,000 $6,850 $6,850

Family-Network $8,000 $13,700 $13,700

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ACA and Exchanges

Beginning January 1, 2016, each BlueEssentials individual plan will include limited dental and limited vision benefits for all members – not just children. • Vision services are available through VSP* and include:

– One exam per benefit period with a $20 copayment for a VSP provider (adults 20 or older).

– One exam per benefit period with a $25 copayment (members 19 or younger)

• Preventive dental benefits include: – One exam every six months ($27 allowance first visit and $20 on the second) – One cleaning every six months ($40 allowance for adults 20 or older and $31

for children)

*VSP is an independent company that offers eyecare benefits and services on behalf of BlueCross plans.

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ACA and Exchanges BlueCross is adding a Wellness Plus benefit for 2016 Exchange plans (small group and BlueEssentials) that provides an additional benefit toward preventive screenings. This benefit applies towards preventive services and screenings that are not covered 100 percent under the United States Preventive Service Task Force (USPSTF) guidelines.

– Individual Plans (BlueEssentials) - $500.00 – Small Group Plans - $300.00 (optional)

Examples of such services include CBC testing, vitamin D tests, and chest x-rays.

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ACA and Exchanges

To view the benefits and features of each BlueEssentials Plan, visit www.SouthCarolinaBlues.com.

BlueCross Exchange Plans: Benefits and Features

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ACA and Exchanges BlueChoice® Exchange Plans: Small Group Plans Business Advantage plans are a line of small group plans BlueChoice offers to businesses with two to 50 employees. These plans use the existing BlueChoice Commercial Network.

Alpha Prefixes ZCL Small Group Private

ZCG Small Group FFM

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ACA and Exchanges BlueChoice® Exchange Plans: Individual (Non-Commercial) Plans BlueOption SM is a line of individual plans BlueChoice offers The network name indicates that the Blue Option Network is being used.

Alpha Prefixes ZCJ Individual Private ZCX Individual FFM

Members do not have out-of-

network benefits.

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ACA and Exchanges 2016 Blue Option Benefit Examples Gold 800 Silver 400 Bronze 4500

DEDUCTIBLES

Individual Deductible $800 $400 $4,500

Family Deductible $1,600 $800 $9,000

SERVICES

Office Visits $20 PCP, $50 specialist 50% coinsurance for PCP and specialist

$45 PCP, deductible then 50% coinsurance

Inpatient Facility Services $300 copay, then deductible, then 30% coinsurance 50% coinsurance $300 copay, deductible then 50%

coinsurance

Outpatient Facility Services 30% coinsurance 50% coinsurance Deductible then 50% coinsurance

Emergency Room $300 copay, then deductible, then 30% coinsurance 50% coinsurance $300 copay, deductible then 50%

coinsurance

Mental Health 30% coinsurance 50% coinsurance Deductible then 50% coinsurance

COINSURANCE MAXIMUM

Individual-Network $3,500 $6,600 $6,850

Family-Network $7,000 $13,200 $13,700

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ACA and Exchanges www.BlueOptionSC.com

Take a moment to check out all the available plans on www.BlueOptionSC.com.

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ACA and Exchanges Covered Drug List You can review our 2016 Covered Drug List for both BlueCross and BlueChoice Exchange plans on our websites.

Caremark* handles prior authorization questions about:

• Step therapy • Formulary exceptions

*Caremark is an independent company that manages all specialty pharmacy drug benefits on behalf of BlueCross and BlueChoice.

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ACA and Exchanges Utilization Management Types of service or treatment that require authorization include: • Hospital admission, including maternity

notifications • Skilled nursing facility (SNF) admission • Continuation of a hospital stay

(remaining in the hospital or SNF for a period longer than was originally approved) for a medical condition

• Outpatient chemotherapy or radiation therapy (through NIA)

• Outpatient hysterectomy or septoplasty • Home health care or hospice services • Certain labs (through Avalon)

• Durable medical equipment, when the purchase price or rental is $500 or more

• Admissions for habilitation, rehabilitation and/or human organ and/or tissue transplants

• Treatment for hemophilia • Mental health and substance use disorders • Certain prescription drugs and specialty

drugs • Advanced radiological services (through

NIA) • Cosmetic procedures

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ACA and Exchanges Reminder: • Maternity benefits vary by plan. Some Plans have a one-time

copay for maternity care while others apply a deductible and coinsurance.

• Continue to bill global maternity the same as commercial products.

Plan Name 2016 Prenatal and Postnatal Care Delivery and All Inpatient Services

Gold 800 $50 copay first visit $300 copay, deductible and 30% coinsurance

Silver 400 50% coinsurance 50% coinsurance

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ACA and Exchanges Transition of Care Form We cover out-of-network providers for emergency care only. In certain situations, individual exchange plan members may receive treatment from an out-of-network physician. • If a physician is not in the individual

Exchange Network and a member has a condition for which he or she is under that physician’s care, and he or she wants to continue with that physician for a duration the transition of care form is necessary.

• The member must complete the request prior to services and the request must be approved in order to be covered.

• The form is on our websites.

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ACA and Exchanges Helpful Resources • Top 10 Reminders • Health Insurance Marketplaces

(Exchanges) presentation • ID Card Guide • Frequently Asked Questions • BlueEssentials Plans • Blue Option Plans

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• Welcome & Introductions • ACA and Exchanges • Federal Employee Program

(FEP) Jada Addison • State Health Plan • Preferred Blue® (PPO) • BlueChoice® HealthPlan of


Medicaid • BlueCard® Program

• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider

Reminders • Closing

Agenda

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Federal Employee Program (FEP)

Standard Plan

Basic Plan

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Federal Employee Program (FEP) Standard Option 2015 2016

Deductibles

Individual $350 $350

Self-Plus One Not applicable $700

Family $700 $700

Services

Office Visits $20 PCP copay $30 Specialist copay

$25 PCP copay $35 Specialist copay

Outpatient Facility Services 15% Coinsurance 15% Coinsurance

Emergency Room 15% Coinsurance 15% Coinsurance

Catastrophic Maximums

Individual (Network) $5,000 $5,000 (Preferred)

Self-Plus One (Network) Not applicable $10,000 (Preferred)

Family (Network) $6,000 $10,000

Individual (OON) $7,000 $7,000

Self-Plus One (OON) Not applicable $14,000

Family (OON) $8,000 $14,000

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Catastrophic Out-of-Pocket Maximum

Self Plus One Not applicable

When one family member reaches the out-of-pocket maximum ($5,000 for Preferred or $7,000 for a combination of Preferred and Non-Preferred) during the calendar year, that member’s claims will no longer be subject to associated member cost-sharing amounts for the rest of the year Self and Family

All family members required to satisfy the maximum, in combination, before any member’s claims were no longer subject to associated member cost-sharing amounts for the rest of the year

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Services

Office visits, physical therapy, speech therapy, occupational therapy, cognitive therapy, vision services, and foot care services performed by Preferred primary care providers or other health care professionals

$20 copay per visit $25 copay per visit

Office visits, physical therapy, speech therapy, occupational therapy, cognitive therapy, vision services or foot care services performed by Preferred specialist


Professional mental health and substance abuse services by Preferred provider $20 copay per visit $25 copay per visit

Manipulative Treatment by Preferred provider $20 copay per visit $25 copay per visit

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Services

Inpatient admission to a Preferred hospital $250 per admission copay $350 copay for unlimited days

Inpatient admission to a Non-member hospital

$350 per admission copay plus 35% of the plan allowance for Member and Non-member providers

$450 copay for duration of services, plus 35% of the Plan allowance and any remaining balance after our payment

Outpatient observation services by Preferred facility

Calendar year deductible and 15% coinsurance when billed by a Preferred facility

$350 copay for the duration of services

Outpatient observation services by Non-member (out-of-network) facility

35% coinsurance when billed by a non-member facility

$450 copay for duration of services, plus 35% of the Plan allowance and any remaining balance after our payment

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Services

Continuous Home Hospice care by Preferred providers $250 per episode copay $350 per episode copay

Continuous Home Hospice care by Member or Non-member providers $350 per episode copay

$450 per episode copay; for non-member providers, member is responsible for 35% of the plan allowance, plus any remaining balance after our payment along with $450 per episode copay

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Federal Employee Program (FEP) Basic Option 2015 2016

Deductibles

Individual $0 $0

Self-Plus One Not applicable $0

Family $0 $0

Services

Office Visits $25 PCP copay $35 Specialist copay

$30 PCP copay $40 Specialist copay

Outpatient Facility Services $100 copay $100 copay

Emergency Room $ 125 copay $125 copay

Catastrophic Maximums

Individual (Network) $5,500 $5,500

Self-Plus One (Network) Not applicable $11,000

Family (Network) $7,000 $11,000

Individual (OON) No coverage out of network No coverage out of network

Self-Plus One (OON) Not applicable No coverage out of network

Family (OON) No coverage out of network No coverage out of network

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Catastrophic Out-of-Pocket Maximum

Self Plus One Not applicable

When one family member reaches the out-of-pocket maximum ($5,500 for Preferred) during the calendar year, that member’s claims will no longer be subject to associated member cost-sharing amounts for the rest of the year

Self and Family

All family members required to satisfy the maximum, in combination, before any member’s claims were no longer subject to associated member cost-sharing amounts for the rest of the year

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Services

Office visits, reproductive services, allergy care, treatment therapies, physical therapy, speech therapy, occupational therapy, cognitive therapy, hearing services, vision services, foot care services, alternative treatments or diabetic education by Preferred primary care providers or other health care specialists


Office visits, reproductive services, allergy care, treatment therapies, physical therapy, speech therapy, occupational therapy, cognitive therapy, hearing services, vision services, foot care services, alternative treatments or diabetic education by Preferred specialists or other health care specialists


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Services

Mental health care and substance abuse services by Preferred providers $25 per visit $30 copay per visit

Manipulative treatment services by Preferred providers $25 copay per visit $30 copay per visit

Home nursing visits by Preferred providers $25 copay per visit $30 copay per visit

Outpatient observation services by Preferred hospital or freestanding ambulatory facility $100 per day per facility $175 per day up to a

maximum of $875

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Federal Employee Program (FEP) Standard and Basic Option 2015 2016

Services

Ultrasound for abdominal aortic aneurysm

Test available to all adult members once per calendar year

Limited to one test per lifetime for adults age 65 to 75

Osteoporosis screening Available for women age 60 and older once per calendar year

• Available for women ages 50 to 65 that have increased risk based on family history or women 65 and older

• Available once per calendar year

Hepatitis B screening for adults and adolescents, age 13 and over

Benefits not available Available for adults, and for adolescents, age 13 and older

Low-dose aspirin Benefits not available Available as a preventive medication for pregnant women who are at risk for preeclampsia

Fluoride varnish Benefits not available Available up to two per calendar year for children through age 5, when administered by a primary care provider

Allergy care and prescription drug benefits Benefits not available Available for specific FDA-approved drugs for

sublingual therapy desensitization

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Services

Inpatient MHSA services provided at an accredited residential treatment center (RTC)

Benefits only available to Standard Option members with primary Medicare Part A coverage

• Benefits available for treatment of medical, mental health, and/or substance abuse conditions

• Requires preliminary treatment and discharge plan developed

• Has to be agreed upon by member, case manager and RTC prior to admission

• Pre-authorization is required

Outpatient dialysis services

Plan allowance was equal to the billed charge for patient dialysis services performed by Non-member facilities

Local Plan allowance used as our Plan allowance when performed by Non-Member facilities

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Federal Employee Program (FEP) Standard and Basic

Option 2015 2016

Services

Bariatric surgery

• Outpatient facility expenses reduced when performed at a BDC for laparoscopic gastric banding surgery. Pre-surgical requirements apply. Standard option ($100 per day per facility) / Basic option ($25 per day per facility)

• Must pre-certify and verify facility designation as BDC

• Now expanded to include laparoscopic gastric stapling surgical procedures

• Standard option ($100 per day per facility) / Basic option ($25 per day per facility)

• Must still pre-certify and verify facility designation as BDC

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Services

*BRCA testing

• Family history criteria expanded to include both breast and fallopian tube cancer as well as breast and peritoneal cancer

• Genetic counseling and evaluation services are required before testing (when performed as a preventive service)

• Prior approval is required for preventive and diagnostic testing

• Testing is available for members (18 and over) when certain criteria is met

• BRCA1 and BRCA2 testing available for individuals 18 and over who are from a family with known BRCA1/BRCA2 mutation

• Includes testing for members who have a personal history of breast, ovarian, fallopian tube, peritoneal, pancreatic and/or prostate cancer, who have not received testing, when genetic counseling and evaluation supports BRCA testing

• Includes testing for large genomic rearrangements in BRCA1 and BRCA2 genes

• Prior approval is required for preventive and diagnostic testing and members have to receive genetic counseling

*Additional requirements apply

Intensity modulated radiation therapy (IMRT) services

Pre-authorization is required for services related to the treatment of anal cancer

No pre-authorization required for services related to the treatment of anal cancer

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Wellness Benefits for Members

Online Health Coach goals

• Eligible for up to $35 in rewards upon completion of Blue Health Assessment (BHA)

• Goals are exercise, nutrition, weight management, stress, and emotional health

• $120 in rewards ($50 for BHA and $40 for each goal) available to members who achieve three Online Health Coach goals

• New goals are heart disease, heart failure, COPD and asthma

Blood pressure monitor

• Available to members who were eligible and enrolled in the Plan’s Coronary Artery Disease (CAD) Management Program

• Available to members with high blood pressure who complete the BHA

• Available every two years through Hypertension Management Program

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Pregnancy Care Incentive Program Not available

• Available for pregnant members 18 and over who receive prenatal care in the first trimester of their pregnancy

• Must complete BHA • Must enroll in My Pregnancy Assistant • Must submit a copy of the provider’s medical record

documenting the prenatal care visit • Members can earn Pregnancy Care Box and $75 toward

a qualified health account

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Federal Employee Program (FEP)

Standard and Basic Option Reminder


Diabetes Management Incentive Program

• Must complete BHA • Available for members age 18 and over • Up to $75 in rewards

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Federal Employee Program (FEP) Updates and Reminders • FEP member information is now available on My

Insurance ManagerSM

• FEP Blue Website is www.FEPBlue.org • FEP telephone number is 888-930-2345

http://www.fepblue.org/

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(FEP) • State Health Plan Jada

Addison • Upstate 1 Networks • Preferred Blue® (PPO) • BlueChoice® HealthPlan of


Medicaid


Agenda

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State Health Plan

State Standard Plan State Savings Plan

MUSC Health Plan

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State Health Plan Standard Plan 2015 2016

Deductibles

No changes for 2016

Individual $445

Family $890

Copays Office Visits $12

Outpatient Facility Services $95

Emergency Room $159

Coinsurance Maximums Individual (Network) $2,540

Family (Network) $5,080

Individual (OON) $5,080

Family (OON) $10,160

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State Health Plan Savings Plan 2015 2016

Deductibles

No changes for 2016

Individual $3,600

Family $7,200

Copays Office Visits No copayment

Outpatient Facility Services No copayment

Emergency Room No copayment

Coinsurance Maximums Individual (Network) $2,400

Family (Network) $4,800

Individual (OON) $4,800

Family (OON) $9,600

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State Health Plan

– State Standard members who have services rendered at PCMH will have $12 per occurrence physician office copay waived. Both Standard and Savings Plan members who have services rendered at a PCMH will have member coinsurance calculated at 10 percent instead of 20 percent after they meet the deductible.

– No member cost share for routine and diagnostic colonoscopies as allowed by USPSTF performed by participating provider

– No member cost share for adult immunizations as recommended by the Centers for Disease Control and Prevention (CDC) performed by participating provider

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State Health Plan • No member cost share for:

– Prescription tobacco cessation products – Diabetes education performed by participating provider – Contraceptives to subscribers and covered spouses

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State Health Plan Additional Plan Information Updates to Precertifications through My Insurance Manager for State Health Plan: • At the time of pregnancy notification, choose type of service non

procedure and location-home and then search for P-pregnancy notification • At the time of admission for delivery, the facility will choose type of

service-Procedure and location- Inpatient, and then search for Vaginal Delivery or C-Section Delivery

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State Health Plan Additional Plan Information (cont’d) • Updates to Pharmacy

• Effective January 1, 2016, Express Scripts will administer State Health Plan prescription drug benefits.

• The formulary list is available at www.express-scripts.com. • The SCRIPTS database is maintained by South Carolina Department of

Health and Environmental Control (DHEC), which is mandatory for prescribers of opioids. SCRIPTS utilization should be a part of every patient’s initial evaluation and subsequent monitoring and is considered the standard of care. Express Scripts is an independent company that manages pharmacy benefits on behalf of BlueCross.

http://www.express-scripts.com/

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State Health Plan

Additional Plan Information • SHP began covering shingles vaccinations for individuals age 60 and over.

• Flu vaccinations are now covered for all State Health Plans with no member cost share.

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State Health Plan • State Health Plan member information is available on My Insurance

Manager

• State Health Plan Website is www.statesc.southcarolinablues.com • State telephone number is 800-444-4311

http://www.statesc.southcarolinablues.com/

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(FEP) • State Health Plan • Upstate 1 Networks Sharman Williams • Preferred Blue ® (PPO) • BlueChoice® HealthPlan of


Medicaid


Agenda

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Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks

– BlueCross and BlueChoice® have partnered with MyHealth First Network (MyHFN) to offer an array of small group Exclusive Provider Organization (EPO) or narrow network products beginning January 1, 2016.

– Created to serve small employers (two to 50 employees) in six Upstate counties:

Upstate 1 Networks

MyHFN is a clinically integrated narrow network of providers who collaborate and share a common goal of improving health outcomes, reducing health care costs and enhancing the patient experience.

Abbeville Laurens

Greenville Oconee

Greenwood Pickens

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Blue Exclusive Upstate 1 – BlueCross ID Card – Exclusive Provider Organization (EPO)

Upstate 1 Networks

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BusinessADVANTAGE Select Upstate 1

– BlueChoice HealthPlan® ID Card – Exclusive Provider Organization (EPO)

Upstate 1 Networks

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BusinessADVANTAGE Select Upstate 1 High Deductible Health Plan (HDHP)

– BlueChoice HealthPlan® ID Card – Exclusive Provider Organization (EPO)

Upstate 1 Networks

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Blue Exclusive Upstate 1 and BusinessADVANTAGE Select Upstate 1 Networks • EPO networks consist of these various provider types in the Upstate

region of South Carolina:

Upstate 1 Networks

Ancillary Providers

Doctors Care (All SC locations EXCEPT those

within the six county EPO network and Newberry County)

Pharmacies Caremark’s list of national and

South Carolina pharmacies

Clinics Hospitals Primary Care Providers CVS Minute Clinics

(All SC locations) MD360

Express Medical Care Specialists

Important: There are no out-of-network benefits, except for true emergency services provided in an emergency room setting.

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(FEP) • State Health Plan • Upstate 1 Networks • Preferred Blue® (PPO)

Sharman Williams • BlueChoice® HealthPlan of


Medicaid


Agenda

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ID Cards

Preferred Blue® (PPO)

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2016 New Groups: Group Name Alpha Prefixes

Aiken County ZCW Comporium Communications FQC Ingevity INV Tire Centers THI United Sporting Companies To be assigned Roper Hospital FRA Southern Management To be assigned Lexington Medical Center ZCW

Preferred Blue® (PPO) 2016 New Network Product:

Group Name Alpha Prefix(es) Business Blue Exclusive Upstate 1 JJD

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BlueCross BlueShield of Illinois: Boeing Clinically Integrated Network

Preferred Blue® (PPO)

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2016 New Groups: Group Name Alpha Prefixes

Aiken County ZCW Comporium Communications FQC Ingevity INV Tire Centers THI United Sporting Companies To be assigned Roper Hospital FRA Southern Management To be assigned Lexington Medical Center ZCW

Preferred Blue® (PPO) 2016 New Network Product:

Group Name Alpha Prefix(es) Business Blue Exclusive Upstate 1 JJD

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South Carolina Sharman Williams

• BlueChoice HealthPlan Medicaid

• BlueCard® Program • Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider


Agenda

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ID Cards

Visit www.BlueChoiceSC.com, on the Doctor & Hospital Finder page, to view BlueChoice HealthPlan® products and

networks.

BlueChoice® HealthPlan Product Name

Network Name

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Products Not Offered in 2016:

Plan/Product Name MyChoice: Open Access MyChoice: Individual Coverage MyChoice: Open Access HDHP MyChoice: Individual Coverage HDHP MyChoice: Open Access Value Plan CarolinaADVANTAGE MyChoice (Primary Choice – HMO) CarolinaADVANTAGE HDHP

Current members can remain in these Plans.

Always ask for a current ID card to verify eligibility and benefits.

BlueChoice® HealthPlan

Alpha Prefix Group Name Plan/Product Name ZCC Lexington Medical Center MyChoice (Primary Choice – HMO)

Current members will have new coverage in 2016.

2016 New Network Product: Group Name Alpha Prefixes

BusinessADVANTAGE Select Upstate 1 ZCI

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These services no longer require prior authorization when performed by a PCP:

Procedure CPT/HCPCS Code(s) Colonoscopy 45378-45392 Continuous overnight pulse oximetry 94762 Excision of nail 11720-11755

Flexible sigmoidoscopy 45300, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45339, 45340

Iron injection* J1750 Paring or cutting of benign lesions 11055-11057

Spirometry 94010, 94014, 94015, 94016, 94060, 94070, 94375, 94620

Removal skin tags 11200-11201 U/S bone density measurement (peripheral) 76977

A list of these services can be found in the BlueChoice Provider Manual and the Provider News page of www.BlueChoiceSC.com.

*Not covered for Health Insurance Marketplace (Exchanges) Plans


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Diabetic members can receive a routine eye exam (office visit and refraction only), covered at 100 percent of allowable charges.

• Members must use a Physician EyeCare Network provider and the self-referral authorization form.

• This benefit is valid for one visit with the following codes: – New Patient: 92004 – Established Patient: 92014 – Refraction: 92015 – ICD-10 Primary Diagnosis Codes: E10.9, E11.0, E11.9, E10.65, E11.65,

E11.8, E11.311, E11.319, E11.36, E11.39 Physician EyeCare Network is an independent company that offers vision care services on behalf of BlueChoice.


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• Authorization is not required for Durable Medical Equipment $499 and under.

• Continue using www.BlueChoiceSC.com for all available provider resources.



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(FEP) • State Health Plan • Upstate 1 Network • Preferred Blue® (PPO) • BlueChoice® HealthPlan of

South Carolina • BlueChoice® HealthPlan

Medicaid Jon Keith, Donna Thompson, Tom Ingram, Donese Pinckney



Agenda

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BlueChoice HealthPlan Medicaid Who We Are • BlueChoice HealthPlan Medicaid entered the South Carolina

Medicaid marketplace in 2008. After seven years of dedicated service to our member and provider communities, our health plan is continuing its strong momentum. We are still growing. Our staff is dedicated to Medicaid.

• We are approved in all 46 South Carolina counties.

• We have approximately 80,000 members.

• We have approximately 12,363 providers in our network.

• We have 59 participating hospitals in our network.

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BlueChoice HealthPlan Medicaid Tools to Assist You • Membership Reports – We update these reports monthly for our PCPs. They identify all

members we assign to each physician within a PCP group. These reports are available via our Provider Access, secured website.

• Medical Loss Ratio Reports – We generate these reports on a quarterly basis for our PCPs. They indicate a cost breakdown associated with the specific practice.

• Emergency Room (ER) Diversion Reports – We generate these reports monthly for our PCP providers. They identify those members who we assign to your physicians and who have visited the ER within the last month. The reports also indicate the member’s diagnosis at the time of his or her ER visit.

• Gaps in Care Reports – We generate these reports monthly for our PCPs. These reports identify members you need to see for well exams, immunizations, etc.

77

BlueChoice HealthPlan Medicaid BlueBlastSM

• The BlueBlast is a monthly, provider-focused newsletter.

• It typically includes: • Important health plan updates • Healthy Connections announcements • Billing and claims information • Frequently asked provider questions • Community outreach efforts and

upcoming events • If you would like to begin receiving a

copy of the BlueBlast electronically or via mail, please contact your Provider Relations representative.

78

BlueChoice HealthPlan Medicaid Contacts

Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product.

Website: www.BlueChoiceSCMedicaid.com Provider Care Center: (Verify eligibility, benefits, claims status, general questions, etc.) • Voice: 1-866-757-8286 Monday to Friday: 8 a.m. to 6 p.m. • Fax: 1-912-233-4010 or 1-912-235-3246 TTY: 1-866-773-9634 24-Hour Nurseline: (Registered nurses provide health information on illnesses and options for accessing care, including emergency services, if applicable.) • Voice: 1-866-577-9710 TTY: 1-800-368-4424

http://www.bluechoicescmedicaid.com/

79

BlueChoice HealthPlan Medicaid Contacts Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product.

Utilization Management: [Prior authorization (PA) and hospital/facility admission notification] • Voice: 1-866-902-1689 Monday to Friday: 8 a.m. to 5 p.m. • Fax: 1-800-823-5520

Case Management: Care coordination and Women Infant and Children (WIC) information: • Voice: 1-866-757-8286 Monday to Friday: 8 a.m. to 5 p.m. • WIC: 1-800-868-0404 24 hours a day, seven days a week

80

BlueChoice HealthPlan Medicaid Contacts Remember, all contact information for BlueChoice HealthPlan Medicaid is different from BlueChoice HealthPlan, the commercial product.

Disease Management: (Programs for chronic conditions) • Voice: 1-888-830-4300 • TTY: 1-800-855-2880

Express Scripts, Inc.: • Voice: 1-866-310-3666 Monday to Friday: 8 a.m. to 9 p.m. • Fax: 1-866-807-6241 Saturday to Sunday: 8 a.m. to 6 p.m.

Vision Service Plan (VSP): • Voice: 1-888-830-4300 • TTY: 1-800-855-2880 Monday to Friday: 8 a.m. to 10 p.m.

81

BlueChoice HealthPlan Medicaid Pharmacy Network • Effective 11/1/15 we have a new pharmacy network. • This network excludes Walgreens. • Pharmacies still in network: —BI-LO

—CVS —K-Mart —Kroger —Longs

—Publix —Rite Aid —Target —Walmart

82

BlueChoice HealthPlan Medicaid Most Common Denials Ineligible Members at the Time of Service • Preferred tool for checking eligibility. • This portal provides information on

– What MCO covers the member. – The health plan anniversary date. The

anniversary date indicates when a member should renew.

– The beneficiary’s third party payers, if he or she has additional health coverage.

83

BlueChoice HealthPlan Medicaid Most Common Denials Ineligible Members at the Time of Service • https://portal.SCMedicaid.com/.

Or contact SCDHHS’ Provider Care Center at 1-888-289-0709 to request access to this site.

https://portal.scmedicaid.com/

84

BlueChoice HealthPlan Medicaid Identification (ID) Card

In addition to the BlueChoice HealthPlan Medicaid member ID card, members are required to carry their SCDHHS-issued Healthy Connections ID cards.

85

BlueChoice HealthPlan Medicaid Most Common Denials Out-of-Network (OON) Claims Denial • The top OON denial reasons include:

₋ Claims filed with no rendering NPI in block 24J. ₋ Billing with a non-credentialed physician/practitioner as the rendering ₋ Billing with a physician assistant as the rendering

99213 Rendering NPI

Billing NPI Number Billing NPI Number

Tax ID Number

01 01 12

Physical Address Billing Address

11

T1015 RHC NPI

RHC NPI Number RHC NPI Number

Tax ID Number

01 01 12

RHC Physical Address RHC Billing Address

72

Claims filed with an incorrect or no rendering NPI RHC claims filed with an incorrect or no rendering NPI

86

BlueChoice HealthPlan Medicaid Most Common Denials Duplicates • When we deny a claim, it isn’t a good idea to

refile the claim. Duplicate claims submissions will cause additional denials.

• If you are unsure about the reasons for your claim’s denial, please contact the Provider Care Center.

• When submitting a hard copy corrected claim, please attach a Claims Follow Up form. You can submit this form electronically.

To access this form, visit:

http://www.BlueChoiceSCMedicaid.com/UserFiles/bluechoice/Documents/Providers/Claim_Followup.pdf

http://www.bluechoicescmedicaid.com/UserFiles/bluechoice/Documents/Providers/Claim_Followup.pdf



87

BlueChoice HealthPlan Medicaid Steps to Claims Resolution • Check claims status via the Web at www.BlueChoiceSCMedicaid.com • Contact the Provider Care Center at 1-866-757-8286. Please remember to

get the name, date and reference number of the Provider Care Center representative.

• If you need further assistance, you can reach out to your Provider Relations

representative.

http://www.bluechoicescmedicaid.com/

88

BlueChoice HealthPlan Medicaid Claims Submission Electronic Data Interchange (EDI) [Payer ID 00403]

• Preferred and fastest way to submit claims • You can also submit corrected claims electronically through EDI • To register or to submit questions, call 1-800-470-9630

Hard Copy Claims Submissions, Corrected Claims and Correspondence

• To submit a hard copy claim, corrected claim, appeal or any type of correspondence, please send mail to:

BlueChoice HealthPlan Medicaid Attn: Medicaid Claims P.O. Box 100124 Columbia, SC 29202-3124

89

BlueChoice HealthPlan Medicaid Provider Updates • Providers are now required to be enrolled directly with SCDHHS.

• All SCDHHS manuals have updated section 1, pages 1-10 to reflect this change.

• Please ensure that all of your practitioners are enrolled with SCDHHS and have been assigned a Medicaid number.

• SCDHHS assigns Medicare numbers

90

BlueChoice HealthPlan Medicaid Incentives • Notice of Pregnancy (NOP)

• Notice of Delivery (NOD)

• Screening Brief Intervention and Referral to Treatment (SBIRT)

• Quality Incentive Program

• ACA Enhanced Reimbursement

91

BlueChoice HealthPlan Medicaid Utilization Management

₋ UM Intake Fax: 1-800-823-5520 | Phone: 1-866-902-1689

₋ Pharmacy Requests: 1-800-470-0933

92

BlueChoice HealthPlan Medicaid Utilization Management Denials I have a denial, what can I do?

• Only the medical director issues denials and can overturn them.

• Read your copy of the denial letter. This contains important information about the rationale for the denial. (If the denial is based on network status, contact your provider relations representative.)

• A treating medical doctor (MD) should call 1-866-902-4628 for a peer to peer (P2P) review. The P2P review provides real-time discussion of the treatment for the member.

• Submit appeals by calling the Provider Care Center at 1-866-757-8286. There is a 90-day calendar timeframe from the date of the denial notification to file an appeal.

93

BlueChoice HealthPlan Medicaid Need Assistance? • Our Quality Management department looks forward to partnering with

you as we pursue our mutual goal of providing access to high quality care and service to members.

• Have questions?

– For HEDIS, call our Clinical Quality Management department at 1-803-382-5170

94

BlueChoice HealthPlan Medicaid BlueChoice HealthPlan Medicaid In the Communities We Serve!

95

BlueChoice HealthPlan Medicaid Value-Added Benefits • SafeLink Cell Phone Program

– Free phone and 350 monthly minutes – Unlimited text messages – Free calls to BlueChoice HealthPlan Medicaid – Text messages with health tips and reminders – 200 bonus minutes – 100 minutes on birthday

96

BlueChoice HealthPlan Medicaid Value-Added Benefits • Free Boys & Girls Club memberships at participating locations (does not

include summer camp) • Free statewide Girl Scout memberships (plus free uniform or journey

book for girls K-5th grade) • Prenatal Rewards Program

‒ Free gift cards (for healthy behaviors) ‒ Free educational booklets ‒ Community baby showers

• Free car seat for pregnant moms (eligibility requirements apply) • Free manual breast pumps

97

BlueChoice HealthPlan Medicaid Community Outreach Team For questions about community outreach initiatives, please contact:

• Daphney Addison, Outreach Specialist Sr. (PeeDee Region) Direct: 803-605-9843 Email: [email protected]

• David Rojas, Outreach Specialist Sr. (Upstate Region) Direct: 803-391-1299 Email: [email protected]

• Letitia Lindsay, Outreach Specialist Sr. (Midlands Region) Direct: 803-231-9138 Email: [email protected]

• Chiara Lazarus, Outreach Specialist Sr. (Low Country) Direct: 803-521-9436 Email: [email protected]

Donna Williams, Marketing Officer Direct: 803-260-6085 Office: 803-382-5167

Email: [email protected]

mailto:[email protected]





2016 Benefit Update Meeting

BREAK

99




Medicaid

• BlueCard® Program Sandy Sullivan

• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider


Agenda

100

BlueCard Program Overview • The BlueCard program enables Blue Plan members to get health care

service benefits and savings while traveling or living in another Blue Plan’s service area. The program links participating health care providers across the country and internationally through a single electronic network for claims processing and reimbursement.

• The BlueCard program lets you submit claims for Blue Plan members directly to your local BlueCross BlueShield of South Carolina Plan.

• We will be your point of contact for education, contracting, claims payment/adjustments and problem resolution.

How to Identify BlueCard Members When members of Blue Plans arrive at your office or facility, be sure to ask them for their current Blue Plan membership ID cards. The ID cards may have:

– PPO in a suitcase logo – PPOB in a suitcase logo – A blank suitcase logo

101

BlueCard Program

Home Plan The Plan that holds the patient’s membership and benefits information.

Responsibilities:

– Enrollment process, issuing ID cards and utilization management. – Benefit, membership and eligibility determination. – All member interactions including member service calls and education. – Claim adjudication (benefit application) and creation of member EOBs.

102

BlueCard Program

103

BlueCard Program Host Plan The Plan that is local for the provider that renders services.

Responsibilities: – Perform provider contracting, training and education. – Receive claims from local providers and price claims. – Route claim information with pricing data to the Control/Home Plan. – Send remittance notice and reimbursement to provider. – Handle ALL provider inquiries and provider service.

1. Member of another Blue Plan receives services from the provider.

2. Provider submits claim to the local Blue Plan.

3. Local Blue Plan recognizes BlueCard member and transmits standard claim format to the member’s Blue Plan.

4. Member’s Blue Plan adjudicates claim according to member’s benefit plan.

5. Member’s Blue Plan issues an EOB to the member.

6. Member’s Blue Plan transmits claim payment disposition to the local Blue Plan.

7. Local Blue Plan pays the provider.

104

BlueCard Program How Claims Flow through BlueCard This is an example of how claims flow through BlueCard.

105

BlueCard Program Medical Records If records are requested: • Forward all requested medical records

to BlueCross BlueShield of South Carolina within 10 calendar days.

• Follow the submission instructions given on the request, using the specified physical or email address or fax number. Include your fax number, too.

106

BlueCard Program The Electronic Provider Access (EPA) Tool • Enables you to use My Insurance Manager to access out-of-area

members’ Blue Plan (Home Plan) provider portals through a secure routing mechanism to conduct electronic pre-service review.

• A separate sign-on is not required once you have been routed to the Home Plan landing page.

• The availability of electronic provider access (EPA) will vary depending on the capabilities of each Home Plan.

107

BlueCard Program BlueCard Precertification/Medical Policies

Access via My Insurance Manager • Check medical policies • Get general precertification

requirements for out-of-area Blue patients

• Get contact information to initiate precertifications

108

BlueCard Program BlueCard Quick Tips

Request BlueCross BlueShield of South Carolina Member’s Home Plan

Eligibility and Benefits

www.SouthCarolinaBlues.com (My Insurance Manager)

800-676- BLUE (2583)

Prior Authorization View ID card for prior authorization contact info

Claim Submission Not applicable

Claim Status Not applicable

Medical Review Request Not applicable

109

BlueCard Program Helpful BlueCard Education Resources www.SouthCarolinaBlues.com

• BlueCard Program Provider Manual • Webinar trainings • Bulletins


110




Medicaid

• BlueCard® Program • Ancillary Claims

Sandy Sullivan • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider Reminders • Closing

Agenda

111

Ancillary Claims Where to file claims…

Lab Provider

Durable/Home Medical Equipment Provider

Specialty Pharmacy Provider

Where the specimen was collected

Where the equipment or supplies were delivered or purchased

Where the ordering physician is located

Where the referring physician is located

OR

112

Ancillary Claims Ancillary Provider Tips • It is important that you use in-network participating ancillary providers

to reduce the possibility of additional member liability for covered benefits.

• Members are financially liable for ancillary services not covered under their benefit plan. – It is the provider’s responsibility to request payment directly from the

member for non-covered services.

Physicians should only refer patients to in-network lab processing and drawing stations.

113




Medicaid • BlueCard® Program • Ancillary Claims

• Avalon Healthcare Solutions Kathy Wade, Kerri Fritsch

• Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider Reminders • Closing

Agenda

114

Avalon Healthcare Solutions • The cost of health care is rising for everyone and we have an obligation to

ensure that our members receive the highest quality of care at the most affordable cost. Laboratory medicine is continuing to become increasingly complex. As technology improves, the cost and utilization of these services increase. This program will assist us in ensuring appropriate testing for our members at the lowest out-of-pocket cost.

• We have partnered with Avalon Healthcare Solutions, a clinical services and information technology company providing comprehensive diagnostic laboratory management services to health plans.

• Avalon will administer a comprehensive suite of laboratory benefit management services to promote patients access to affordable, high-quality health care.

115

Avalon Healthcare Solutions • Over 4,000 different lab tests exist, and the menu continues to increase in

size, complexity and cost • Over 9 billion tests are performed each year, more than any other health

care procedure • Lab tests are the basis for at least 70 percent of clinical decisions • 30 percent of volume represents overused or medically unnecessary

testing, and not ordering a test when clinically appropriate may reach the same level

• Nearly 3 in 4 physicians say unnecessary tests represent a serious problem

116

Avalon Healthcare Solutions • Primary care physicians are uncertain about the appropriate test to order

in 15 percent of diagnostic encounters and uncertain about interpretation of results in 8 percent of cases

• With 500 million primary care patient visits per year, that means 23 million times a year a primary care physician is uncertain about the appropriate use of a diagnostic test

• Between 15 percent and 54 percent of medical errors reported by primary care doctors are related to testing

How Does This Program Affect Physicians? • Sometimes patients may need a specialized test. We considered this issue and

included specialty labs and centers of excellence within the network of laboratory providers. The centers of excellence are staffed by qualified clinical pathologists and genetic counselors prepared to answer your inquiries both before and after you perform testing.

• We do not qualify all laboratories. If an out-of-network laboratory services you or

you have outpatient testing performed by a hospital, your patients’ out-of-pocket cost may be significant. To ensure the lowest cost to your patients, please send BlueCross and BlueChoice members’ testing to in-network laboratories only.

• Please note that Avalon doesn't manage services in an emergency room,

observation room, surgery center or hospital inpatient setting. This change does not alter the available member benefits, but using these participating providers will result in a lower out-of-pocket cost for your BlueCross- and BlueChoice-covered patients.

117

Avalon Healthcare Solutions

118

Avalon Healthcare Solutions • Implementation

– January 1, 2016: New medical policies will take effect that impact laboratory services. We will enforce preauthorization requirements for select laboratory procedures.

– April 1, 2016: Enhanced medical policy administration, including post-service claims edits, will go into effect.

• Remember to use an in-network laboratory to limit your patients’

out-of-pocket costs.

119

Avalon Healthcare Solutions

• Avalon partnered with BlueCross and BlueChoice to provide comprehensive laboratory benefits management services

• The new group of providers were added to the network to increase access to specialized testing • All new and currently contracted providers, including LabCorp, Quest and other large labs, are listed in the BlueCross

BlueShield of South Carolina directory

Aug 2015 2016

RCs 1&2 Program Announcement

Program Intro/Prior Auth

ns

Sept Oct Nov Dec Feb Mar Apr May June July

RCs 1&2 Med Policy Education

RCs 1&2 Effective/ RC 3 Program

Announcement

Webinars

Prior Auth implemented

Claim edits implemented

RC 4 Med Policy Education

RC 3 Effective/ RC 4 Program

Announcement

120

Avalon Healthcare Solutions Medical policies containing precertification elements:

BCR-ALB 1 Testing for Chronic Myeloid Leukemia

BRCA Cardiac Ion Channelopathies

Chromosomal Microarray Cytochrome P450

Epidermal Growth Factor Receptor

Familial Adenomatous Polyposis

Flow Cytometry FLT3 and NPM1 Mutation

General Genetic Testing

Genetic Testing for Cystic Fibrosis

Genetic Testing for Duchenne and Becker Muscular Dystrophy

Genetic Testing for Fanconi Anemia

Genetic Testing for FMR1 Mutations

Genetic Testing for RET Proto-oncogene in Medullary CA of Thyroid

Genetic Testing for Rett Syndrome

HIV Genotyping and Phenotyping

JAK2 and MPL Mutation KRAS and BRAF Li-Fraumeni

Syndrome

Lynch Syndrome Non-Invasive Screening for Aneuploidy

Pre-Implantation Testing

Prenatal Screening

PTEN Hamartoma Tumor Syndrome

121

Avalon Healthcare Solutions Avalon developed a code matrix in an effort to help you determine when you need to contact Avalon for precertification.

You can view this detailed matrix on our website, www.SouthCarolinaBlues.com in the Provider section under Precertification.

Code Description

81205 BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., maple syrup urine disease) gene analysis

81210 BRAF (v-Raf murine sarcomaviral oncogenehomolog B1) (e.g., colon cancer), gene analysis; full sequence

81223 Full gene sequence

81229 Interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities

81245 FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; evaluation to detect abnormal (e.g., expanded alleles)

122

Avalon Healthcare Solutions • You can submit prior

authorization requests by phone, fax or online. Avalon will promptly review your request for medical necessity and provide you with a timely, written decision.

• It is the responsibility of the referring physician to get the authorization, however, the lab may do so if they have the necessary clinical information.

Telephone: 1-844-227-5769 Fax: 1-888-791-2181

123

Avalon Healthcare Solutions Avalon Network The Avalon network of labs is offered as a supplement to the current BlueCross and BlueChoice networks. To verify participating labs visit our Provider Directories found on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com.



124

Avalon Healthcare Solutions Helpful Resources

– Lab Procedures Procedure Authorization Matrix

– News bulletins

– Avalon presentation

– More education to come

125


(FEP) • State Health Plan • Preferred Blue® (PPO) • BlueChoice® HealthPlan of



• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives

Contessa Struckman • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider


Agenda

126

Quality Initiatives • Our goal is to work collaboratively with physicians and hospitals to

impact the health of our members and the community. • Through our joint efforts to reorganize systems of care, we are

working to align incentives to support evidence-based care, share best practices and improve overall health outcomes.

• We know that collaboration with the medical community leads to better long-term quality of life for our members and a more cost-effective health care system.

127

Quality Initiatives Maternity Initiatives: OB/GYN Report Cards • BOI - The number of delivery claims

submitted using the appropriate procedure codes and modifiers

• SBIRT - The number of women who delivered and received a screening and/or a referral to treatment

• C-Section Rate - The number of babies delivered via C-section

• Preterm Rate - The number of babies delivered prior to 37 weeks of gestation

And other categories.

OB/GYN PROVIDER 123456789 123 PINE ST. CITY, STATE

128

Quality Initiatives Helpful Resources – Healthier Moms and Babies

publication • This publication gives you information

about our maternity managed care programs, informs you of helpful tools to engage your patients and provides you with resources to integrate your patient care with our services.

– Maternity Initiatives Presentation – SBIRT Form – Pregnancy Notification Form – OB/GYN Report Cards – Maternity Initiatives FAQs

129

Quality Initiatives

• Healthcare H • Effectiveness E • Data and D • Information I • Set S

HEDIS® This is a tool that measures performance in the delivery of medical care and valuable health services.

• The National Committee for Quality Assurance (NCQA) coordinates and administers HEDIS yearly.

• The Center for Medicare and Medicaid Services (CMS) uses it for monitoring the performance of health plans.

• The tool evaluates both physical and behavioral health clinical practice guidelines (CPG) adherence.

130

Quality Initiatives HEDIS: How is data gathered? • Annually, members are randomly selected for review based on a

predetermined sample size for each measure. • Data is collected throughout the year through retrospective review of

services via claims information and medical records. • Members who have not had a claim submitted for specific services

may be selected to assess barriers and provide information to providers using Gaps in Care Reports.

• Certified auditors rigorously audit HEDIS results using a process designed by NCQA.

131

Quality Initiatives HEDIS: What is a gap in care? Care gaps occur when a member has not received valuable health services.

Gaps in Care

Closure

Quality Improvement

Provider Relations

and Education

Rewarding Excellence

You will receive GIC Reports from your provider

advocate and support in

understanding this quality initiative.

Your physician or practice can gain recognition for

promoting good health and fighting

disease.

Our QI nurses will meet with you for “deep dive” chart

reviews and techniques to closing care gaps.

132

Quality Initiatives Helpful Resources www.SouthCarolinaBlues.com or www.BlueChoiceSC.com

• Gaps in Care Reports • Provider Reference Matrix Guides • HEDIS Charts • Compliance Companion Forms

All of these tools work hand-in-hand to ensure success!

Remember: we are less likely to request medical records when you submit claims with all appropriate procedure and diagnosis codes.



133

Quality Initiatives

Helpful Resources Gaps in Care Reports • ID Card Number • Date of Birth • Gender • Quality Measure

(undocumented or missed care)

134

Quality Initiatives Helpful Resources Available on our websites • Provider Reference

Matrix Guides (shown) • HEDIS Charts • Compliance Companion

Forms (shown)

135

Quality Initiatives HEDIS: 2016 Timeline

Mid-October 2015 Supplemental Review Process Begins Early January 2016

Quality Nurses Onsite Scheduling Begins

Mid-January 2016 Hybrid Medical Records Review

Process begins March 2016

Supplemental Review Process Ends

May 2016 Hybrid Medical record Review

Process Ends

June 2016 Final Rates are Submitted and

Locked

136

Quality Initiatives

As part of CMS data validation activities, we are reviewing charts in an ongoing process seeking to make sure that our records properly reflect the clinical condition(s) of our members.

Talk with patients about their current conditions during every encounter, ensure that the appropriate diagnosis code for each condition is submitted with the claim and

documented in the medical record.

137

Quality Initiatives

• Consumer C • Assessment of A • Healthcare H • Providers and P • Systems S

Patient Surveys: CAHPS CAHPS is a survey designed to support consumers in assessing the performance of their health plans. • Asks consumers (patients) to evaluate

their experiences with health care services

• Survey assesses the communication skills of providers, ease of access to health care services and more topics

• Measures a member’s satisfaction with the health plan, providers, customer service, etc.

138

Quality Initiatives Patient Surveys: CAHPS Survey questions: • Your Health Care in the Last 12

Months – In the last 12 months, when

you needed care right away, how often did you get care as soon as you needed?

• Your Personal Doctor – In the last 12 months, how

often did your personal doctor spend enough time with you?

139

Quality Initiatives •Qualified Q

•Health H

• Plan P

• Enrollee E

• Experience E

• Survey S

Patient Surveys: QHP EES QHP EES is a new consumer experience survey that assesses enrollee experience with the Qualified Health Plans (QHPs) offered through the Marketplaces (Exchanges) • It was circulated nationally for the first

time this year • CMS-approved survey vendors

administered it • Asks consumers and patients to report on

and evaluate their experiences with health care services in the last six months

140

Quality Initiatives Patient Surveys: QHP EES Survey questions: • Your Health Care in the Last Six Months

– In the last six months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?

• Your Personal Doctor – In the last six months, how often

did your personal doctor show respect for what you had to say? Survey information available at

https://qhpcahps.cms.gov/node/47

141

Quality Initiatives Patient Surveys: How can providers influence patient satisfaction and impact survey results? Access to care and care coordination are two areas that you can significantly affect.

Consider: • How easy is it for my patients to get an

appointment? • Do I (doctor) explain things in a way my

patients can understand?

Refer to the Improving Patient Satisfaction for Providers publication for articles about care coordination and quality standards.

142

Quality Initiatives Rewarding Excellence: Hospital Program

Rewards top-performing hospitals with increased payments for the quality of care they provide.

Quality measures include key safety and efficiency measures, as well as patient experience.

GOAL: To compensate hospitals for the quality of care provided to patients, not just the quantity of procedures performed.

143

Quality Initiatives Rewarding Excellence: Physician Program

Support quality initiatives to improve health outcomes for members.

Emphasis is based on HEDIS, STARS and Quality Reporting System (QRS) measures.

Help physicians and practices succeed in preventing and closing gaps in care

144

Quality Initiatives What is a Patient-Centered Medical Home (PCMH)?

• Team-based approach to health care led by a physician, nurse practitioner or physician assistant

• Addresses all of a patient’s health care

• Has national recognition as a PCMH

Family Medicine

Practice Organization

Health Information Technology

Quality Measures

Patient Experience

145

Quality Initiatives

PCMH: Why should your practice consider becoming a PCMH?

Overall improved patient outcomes

Performance-based incentives and compensation

Increased satisfaction among physicians-staff-

patients

146





• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management

Ranarda Jones • Web Tools • ICD-10 • Provider Credentialing • Additional Provider


Agenda

147

Pharmacy Management BlueCross Prescription Drug/Medicare Part D • Medicare Part D (PDP product only):

– Has its own formulary and drug management programs – Prime Therapeutics will continue as the pharmacy benefits manager

(PBM) for Part D business. • Plan Name Changes • Pharmacy Network Enhancements • Formulary Changes • Other

148

Pharmacy Management Plan Name Changes for 2016

2015 2016 MedBlue Rx BlueCross Rx Value

MedBlue Rx Plus BlueCross Rx Plus

Same familiar phone numbers and helpful customer service staff. We will mail new ID cards prior to January.

149

Pharmacy Management Pharmacy Network Enhancements • Preferred Pharmacy is new for 2016 for the Value plan • Our preferred network includes some of the major chains as well as

independents • Members will have a lower cost share for prescriptions filled at a preferred

pharmacy versus a standard retail pharmacy • Long Term Care members will receive the preferred pharmacy copayments • 84 percent of BlueCross Rx Value members currently fill their prescriptions at a preferred pharmacy

150

Pharmacy Management Overview of Formulary Changes • BlueCross Rx Value and BlueCross Rx Plus will each use a 5 tier formulary

for 2016 – A given drug may be in different tiers across the two plans

• BlueCross Rx Value formulary – Changes made but meets CMS requirements with at least two drugs

covered per USP class – Shifted some high-cost generic drugs to branded tiers

• BlueCross Rx Plus formulary – Has minimal changes from 2015 formulary – Drugs may be in different tiers from 2015 to 2016

• Same utilization management applies to both formularies (i.e., PA, step, QL)

151

Pharmacy Management BlueCross Rx Value Top Formulary Removals for 2016

Nexium (brand and generic) Avodart (brand and generic)

Glyburide Benicar & Benicar HCT

Levothroid (brand) Celecoxib (generic Celebrex)

Levemir Bystolic

Valsartan/HCTZ Amlodipine/benazepril

Lansoprazole Dexilant

Synthroid (brand) Bisoprolol/HCTZ

Livalo Jalyn

Oxycontin Rabeprazole (generic Aciphex)

Formulary alternatives can be found at www.myprime.com or by using the published formulary document on www.southcarolinablues.com.

http://www.myprime.com/


152

Pharmacy Management Medically Accepted Indication • CMS will not allow a Part D plan sponsor to cover a medication that does

not have a medically accepted indication as approved by the FDA or in CMS-supported compendia

• Examples include: – Cialis, Lidoderm patches and oral Fentanyl Cyclobenzaprine

153

Pharmacy Management Part D Prescriber Regulations • Any physician or other eligible professional who prescribes Part D drugs

must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans.

• Medicare Part D may no longer cover drugs that are prescribed by physicians or other eligible professionals who are neither validly enrolled, nor opted out of Medicare.

• All prescribers should enroll before January 1, 2016 to allow for the processing of applications and to ensure enrollees get their prescriptions.

154

Pharmacy Management BlueCross Rx Value Top Formulary Removals for 2016

Documents found on www.SouthCarolinaBlues.com

• Pharmacy Directory • Summary of Benefits • Annual Notice of Changes and

Evidence of Coverage • Comprehensive Formulary • Coverage Determination

Forms • Information on filing appeals

and grievances

Documents found on www.MyPrime.com

• Searchable Formulary • 2016 Preferred Pharmacy

Finder • PrimeMail New Order Form • Coverage Determination

Forms • Prior Authorization • Step Therapy • Quantity Limits • Formulary Exception

155

Pharmacy Management ACA Business • ACA (Marketplace) products:

– CVS Caremark will continue as the PBM for all ACA formulary and drug management programs.

– The “Covered Drug List” is the name of the formulary list used for the ACA “metal” plans.

– A searchable version of the “Covered Drug List” can viewed by visiting the link, www.SouthCarolinaBlues.com or www.blueoptionsc.com.


http://www.blueoptionsc.com/

156

Pharmacy Management Overview: BlueCross & BlueChoice Commercial Pharmacy Management Update

• Exclusive Specialty Pharmacy Vendor Change for 2016

• New Drug Management Programs under the Medical Benefit

• Utilization Management

• BlueChoice multi-tiered Prescription Drug List

157

Pharmacy Management Specialty Drug What are Specialty Drugs? • Used to treat rare conditions that affect approximately 1 percent of the

population • Generally requires special storage, handling and administration • Expensive treatments that range from $30K to $400,000 annually per patient • Contributing to approximately 30 percent to 40 percent of overall drug costs • Costs are forecasted to increase at a rate of 16 percent to 20 percent annually

Ex: Orkambi • Specialty drug used to treat cystic fibrosis (CF) patients who have a specific gene

mutation • 30,000 CF patients in the US • 15,000 CF patients are candidates for treatment • Improves lung function and is suspected to significantly improve life expectancy • Annual ongoing cost of therapy = $300,000.00

158

Pharmacy Management Preferred Specialty Pharmacy Effective January 1, 2016 • CVS/specialty™ will become the preferred specialty pharmacy vendor for both

BlueCross and BlueChoice commercial and ACA lines of business. CVS/specialty is a division of CVS Caremark, an independent company that provides pharmacy benefit management and specialty pharmacy services on behalf of our members’ health plans.

• Accredo will no longer be in network. • Patients with refills at Accredo, that can legally be transferred, will be auto-

transferred to CVS/specialty on January 1. • We have notified physicians and members who will be impacted by the change.

CVS/specialty will also be contacting members to assist with the transition. Note: These updates do not apply to the State Health Plan.

159

Pharmacy Management Drug Management Programs under the Medical Benefit

Effective April 1, 2016

• Certain drugs administered by a provider and billed through the medical benefit will require prior authorization

• Providers will receive education on how to submit prior authorization requests to the plan via Novologix.

• All drug claims will require you to submit the NDC-11 drug code with the claim when billing for reimbursement under the medical benefit.

160

Pharmacy Management

Rasuvo Xeljanz Acthar Sabril

Hetlioz Oralair

Buphenyl Ravicti

Remicade Rituxan Synagis Simponi Benlysta Grastek

Ragwitek Carbaglu

Drug Management Programs under the Medical Benefit A few examples of drugs that will require prior authorization under the medical benefit effective April 1, 2016 include:

161

Pharmacy Management Specialty Drug List Update • The Specialty Drug List and PA program are dynamic.

• Drugs are added to the Specialty Drug List as soon as they are approved by our P&T committee

• Prior Authorization, when appropriate, will be added as soon as possible.

• We will update the Specialty Drug List every quarter.

162

Pharmacy Management Multi-tiered PDL • BlueChoice began converting groups to the Tiered PDL in August 2015, upon

renewal. This conversion will last throughout 2016. • BlueCross employer group only will also use the Tiered PDL in 2016. • The main difference with the Tiered PDL is that drugs aren’t tied to generic,

preferred and non-preferred copayment levels. Some generic drugs and brands with no added value to more cost-effective options may be at tiers 4 through 6.

Example: omeprazole-sodium bicarb (tier 4), Amrix (tier 5).

163




Medicaid

• BlueCard® Program • Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools Ashlie Graves • ICD-10 • Provider Credentialing • Additional Provider


Agenda

164

Web Tools www.SouthCarolinaBlues.com www.BlueChoiceSC.com

165

Web Tools Education Center

The Education Center is a great place to begin your educational experience! • BlueCard • Medical Policies • Precertification • Training Manuals • Webinars

166

Web Tools Provider News and BlueNewsSM for Providers

167

Web Tools My Insurance Manager

• Secure provider portal • Verify eligibility and benefits • View claim status • Initiate prior authorization

(precertification) requests • Attach medical records to

authorization requests • View remittances • Submit claims inquiries to Ask

Provider Services • Call Provider Services through the

STATchatSM feature

168

Web Tools My Insurance Manager Reminders

• Each user must have a unique username registered in My Insurance Manager. • Due to the security of the information found within My Insurance Manager, you

should never share your login information with anyone. • Please contact us if you feel your username or password has been compromised. • If emails from My Insurance Manager are ending up in your junk folder, you may

be missing out on registration confirmations for new user profiles. • My Insurance Manager can provide you with eligibility information and general

benefits at the service type level for BlueCard members.

169

Web Tools Voice Response Unit (VRU) Faxback

• When you get eligibility and benefits information via our VRU faxback option, we also include our latest education announcements on the cover page.

170

Web Tools Improving the precertification process: We’re reviewing our processes and developing enhancements for you. • Developing guidance to inform you what medical information we need to

complete authorization requests. • Adding services to the Fast-Track option in MIM. • Participating in dedicated workgroups to identify and reduce

inefficiencies. • Designing a form to capture the minimum necessary information for

specific procedures and services. • Designing easier methods for you to submit documentation.

171

Web Tools

Member’s Name Database Number/Subscriber ID Date of Birth

International Classification of Diseases (ICD)

Service: CPT, HCPCS and/or Notification of Emergent Admission

Provider’s Name and Tax ID and the National

Provider Identifier (NPI) number

Initial Precertification Requests

172

Web Tools Initial Precertification Requests

If any of the information is missing, we will deem the request incomplete and return it to the requestor. When this occurs, the requestor will receive this response:

173

Web Tools Initial Precertification Requests Incomplete or missing information can prolong the response time for your requests.

62 pages submitted, missing member ID and no return fax number

Did not submit enough information to approve

authorization

174

Web Tools Clinical Attachments within My Insurance Manager

• This feature is available for services that do not automatically approve. • Records must be in a PDF format (other formats to come!). • You can attach up to 10 documents at a time; the maximum size of a

single attachment is 30MB. • When you select a document, you can preview it to ensure it is exactly

what you want to submit and remove it if necessary. • Once you attach the document has it cannot be reviewed or deleted.

175

Web Tools Clinical Attachments • If we receive a request and need additional clinical information from you, we will

send you a request with a “Request ID” that is unique to that case. • You can add additional documents when checking the authorization status but

you must include the Request ID with future attachments. • Including the Request ID ensures we can easily identify the member’s case and

combine clinical information with the documentation already on file. • Once you attach the file, you will be able to preview the document.

176

Web Tools Precertification Reminders: • Refer to the medical policies we use to make clinical determinations. Our

medical policies are available online and include specific elements we use to evaluate eligibility of a procedure or service for benefit coverage.

• Avoid sending duplicate requests for precertification by phone, fax and online. This creates additional delays. All new and duplicate requests must be worked through as they are received.

• Verify eligibility, benefits and authorization requirements for every member encounter to avoid unnecessary denials.

177

Web Tools Peer-to-Peer Requests • BlueCross physicians will conduct

peer reviews for medical necessity denials .

• If unable to reach the attending physician, we will leave a contact number for the physician to return the call.

• We will transfer requests for Peer-to-Peer reviews received through our call center to the appropriate reviewer for disposition.

178

Web Tools

Secured Authorization Form In 2016 you will be able to submit authorizations through a secured site. You will complete the electronic form based on the service(s) you wish to authorize. You will be allowed you to enter necessary clinical data, too! More information to come.

179

Web Tools

What’s the Best Method?

The chart in your packet identifies the most efficient method to get information for certain services.

Service centers typically experience higher call volumes in the new year as providers verify new benefit plans.

Beginning January 1/1/2016 claim status inquiries will be serviced by first going through My Insurance Manager and then Ask Provider Services if you need further assistance.

180

Web Tools NIA Magellan Many plans require prior authorization for advanced radiology procedures through NIA.

181

Web Tools NIA Magellan • Non-emergency procedures that require pre-authorization are:

– Computed Axial Tomography (CAT) Scan – Positron Emission Tomography (PET) Scan – Magnetic Resonance Imaging (MRI) – Magnetic Resonance Angiography (MRA)

• To request a pre-authorization (PAs) or the status of an preauthorization: – Visit www.RadMD.com or – BlueCross calls to 866-500-7664 – BlueChoice calls to 888-642-9181

http://www.radmd.com/

182

Web Tools NIA Magellan We require prior authorizations for these advanced radiology procedures:

BlueCross BlueChoice CT/CTA scans CT/CTA scans CT Colonography MRI/MRA scans MRI/MRA scans Coronary CTA PET Scans PET Scans MRCP

Nuclear Cardiology Studies Stress Echocardiology

Visit www.SouthCarolinaBlues.com or www.BlueChoiceSC.com for a complete list of alpha prefixes for members who require PAs through NIA, NIA reference guides and frequently asked questions.

183

Web Tools NIA Magellan Radiation Oncology Program

– Became effective January 1, 2015 – NIA Magellan provides the radiation oncology benefit management

services. – The program is designed by physicians to ensure that services

within the radiation therapy treatment plan are clinically appropriate for each patient’s specific condition.

– The program applies to radiation oncology services when performed and billed in an outpatient or office location.

184

Web Tools NIA Magellan Radiation Oncology Program NIA Magellan Radiation Oncology services that require PAs based on medical necessity:

Low-dose-rate (LDR) Brachytherapy

High-dose-rate (HDR) Brachytherapy

Two-dimensional (2D) Conventional Therapy

Three-dimensional Conformal Radiation Therapy (3D-CRT)

Intense Modulated Radiation Therapy (IMRT)

Image Guided Radiation Therapy (IGRT)

Stereotactic Radiosurgery (SRS)

Stereotactic Body Radiation Therapy (SBRT)

Proton Beam Radiation Therapy (PBT)

Intra-Operative Radiation Therapy (IORT) Neutron Beam Therapy Hyperthermia

185

Web Tools NIA Magellan Radiation Oncology Program NIA Radiation Oncology Matrix

• Use this to determine procedures managed by NIA Magellan Procedures and Allowable Billed Groups – Located at

www.SouthCarolinaBlues.com and www.BlueChoiceSC.com

– Refer to the health plan policies if the procedures are not listed in the matrix

186

Web Tools NIA Radiation Oncology Program Participating BlueCross and BlueChoice plans: • Fully insured • BlueCross Exchange plans • BlueChoice Exchange plans • BlueChoice commercial plans

Non-Participating BlueCross and BlueChoice plans: • Federal Employees Program (FEP) • State Health Plan • Self-funded plans • Out-of-state members (BlueCard®)

187

Web Tools Visit www.RadMD.com for additional information about RadMD.

188




Medicaid

• BlueCard® Program • Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 Shamia Gadsden • Provider Credentialing • Additional Provider Reminders • Closing

Agenda

189

ICD-10 What You Need to Know • The use of CPT-4, HCPCS, Revenue Codes, Mental

Health DSM-5 and other codes have not been affected.

What You Need to Do • You may not file a claim with both ICD-9 and ICD-

10 codes. File ICD-9 codes on one claim, and the ICD-10 codes on a separate claim.

• If the date of service is prior to 10/1/2015 you should use ICD-9 codes if the claim is submitted after the compliance date.

190

ICD-10 What You Need to Do • We require the applicable alphanumeric

seventh character for all codes. If necessary, use a placeholder X to ensure the seventh character is in the correct data field.

• Providers can use My Insurance Manager to submit ICD-10 compliant claims to our plans; or resubmit a corrected claim through your clearinghouse.

191

ICD-10 Helpful Resources

– http://www.hipaacriticalcenter.com/icd10.aspx

– https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/SE1408.pdf

– http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10MythsandFacts.pdf

– https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10Introduction20140819.pdf

– https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

– www.ICD10Data.com

192





• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing

Shamia Gadsden • Additional Provider Reminders • Closing

Agenda

193

Provider Credentialing • BlueCross, BlueChoice and BlueChoice HealthPlan Medicaid use the

credentialing process to validate practitioners’ qualifications. • BlueCross and BlueChoice credential all physicians and all mid-level

providers applying for participation in any of our networks. • BlueChoice HealthPlan Medicaid credentials all physicians and all

mid-level providers.

194

Provider Credentialing The Credentialing Process

We receive the application.

We review the application to

ensure it is complete and includes all

required documentation.

We send “clean” applications to the

Credentialing Committee for

review.

If the Credentialing Committee

approves the application , we

send a notification via email, and mail

the executed contracts to the

provider.

If the Credentialing

Committee does not approve the application , it is

sent to the Provider

Disciplinary Committee.

The Provider Disciplinary

Committee either approves or denies the

application.

We send a notification to the

provider.

195

Provider Credentialing You can find these forms in the Forms section of our websites:

South Carolina Uniform Credentialing Application

Registration Form for Mid-Level and Hospital-

Based Providers

South Carolina Uniform Credentials Update

form

Request to Add or Terminate Practitioner

Affiliation

Change of Address

Application for Satellite Location to File Claims or to Change Employer Identification Number

(EIN)

NPI Notification form

Electronic Funds Transfer (EFT) Electronic

Remittance Advice (ERA) Enrollment form

EFT Terms and Conditions form

196

Provider Credentialing Provider Updates Updates we need to know about:

Providers’ names Practice address Telephone number

Fax number Practice office hours Practice URL (website)

Email of Person to contact for provider updates

Provider accepting new patients

Age range and gender of patients accepted

Provider no longer accepting new patients

Physician joining or leaving your practice

New or closed satellite location

197

Provider Credentialing Provider Updates • Send all office updates to [email protected]. • The Provider Certification department will ensure we complete

your updates across all BlueCross and BlueChoice lines of business.


198

Provider Credentialing

Electronic Solutions for Provider Updates In 2016 providers will be able to complete quarterly CMS requirements in a simple electronic format

199

Provider Credentialing Helpful Resources • Credentialing presentation • Network & Credentialing Status inquiries

– Email: [email protected] – Fax: 803-264-4795

• Electronic Funds Transfer (EFT) questions – Email: [email protected] – Fax: 803-870-8065 Attn: EFT Coordinator



200





• Ancillary Claims • Avalon Healthcare Solutions • Quality Initiatives • Pharmacy Management • Web Tools • ICD-10 • Provider Credentialing • Additional Provider Reminders

Teosha Harrison • Closing

Agenda

201

Additional Provider Reminders New Place of Service (POS) Code • CMS is creating a new code POS 19 and revising the current POS code

descriptor for outpatient hospital POS 22:

Place of Service Code Code Descriptor

POS 19 Off-campus outpatient hospital

A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

POS 22 On-campus outpatient hospital

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

• The effective date for these changes is January 1, 2016.

202

Additional Provider Reminders Change to Medicare Advantage (MA) Compliance • CMS developed a compliance and fraud, waste and abuse (FWA) training

module for use by health plans and the entities they partner (contract) with to provide services.

– This was done to reduce the burden on providers who were being asked to complete and attest to multiple compliance and FWA trainings from several insurers.

• Effective January 1, 2016, all MA plans must accept certificates of completion of this CMS Compliance and FWA training (located on the Medicare Learning Network) from network providers.

– Attestations will still be required from contracted network providers in 2016 as we continue to maintain our Medicare Advantage network.

203

Additional Provider Reminders Change to MA Compliance • BlueCross’ MA Compliance will send a letter to network providers

regarding updates to FWA training requirement for 2016.

• Providers can complete “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training” at:

– https://learner.mlnlms.com/ (You must create a user account) – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/ProviderCompliance.html (Download training modules) – http://web.southcarolinablues.com/providers/medicareadvantage.aspx

(under Fraud and Compliance Awareness heading)

https://learner.mlnlms.com/

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

http://web.southcarolinablues.com/providers/medicareadvantage.aspx

204

Additional Provider Reminders Specific Coding and Reporting Be as specific as possible in providing a diagnosis code for patients and all diagnosis codes must be documented in the patient’s medical record. Submit all diagnosis codes appropriate for that patient at every visit.

10,457 records were requested this year.

7,926 could have been avoided by coding claims completely.

205

Additional Provider Reminders Rendering Provider NPI Reporting Requirement • Effective January 1, 2016, BlueCross and BlueChoice will require you to

report the rendering provider NPI on all claims. Any claim we receive without the rendering provider’s information will result in a claim denial.

• We will accept corrected claims if your office happens to omit the rendering provider information. We recommend you submit the claims electronically using My Insurance Manager on our websites at www.SouthCarolinaBlues.com or www.BlueChoiceSC.com for faster processing.

206

Additional Provider Reminders National Drug Code Reporting Requirements Effective January 1, 2016, BlueCross and BlueChoice® will require the reporting of the NDC, NDC unit of measure and NDC quantity for all outpatient-administered drug claims. As a reminder, when submitting NDCs on professional electronic and paper (CMS-1500) claims, you must include this related information:

• 11-digit NDC • NDC qualifier (N4) • NDC quantity • NDC unit of measure (UN – Unit, ML – Milliliter, GR – Gram, F2 –

International Unit) You can find additional information about the NDC requirements or the Drug Rebate Program in the Provider News section of our website at www.SouthCarolinaBlues.com.

207

Additional Provider Reminders New Remittance Codes • Category code P5: Pending/Payer Administrative/System hold • Claim status code 734: Verifying premium payment • Claim status code 1: For more detailed information, see remittance advice • CARC 277: The disposition of the claim/service is undetermined during the

premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)

• RARC N618: Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.

Note that the liability will be Other (OA instead of PR or CO).

208

Additional Provider Reminders Increasing Patient Reviews in 2016

Patient reviews provide insight into your patients’ experiences. The reviews also can attract new patients to your practice. Approximately 85–90 percent of patient reviews are positive. Patients are eligible to post one review per physician encounter. Very few are using this tool!

Providers can log into My Insurance Manager to respond to each patient review.

209

Additional Provider Reminders

As part of our service efforts, we have created Palmetto Provider University. This curriculum educates new providers and their staff on our business objectives and processes.

2016 Webinar Topics 2016 Benefit Update Meeting Encore

Credentialing Health Insurance Marketplace

(Exchanges) BlueCard and Ancillary Services

Quality Initiatives Web Tools

Dental Mental Health

Provider Town Hall Meetings Web Precertification

210




Medicaid


Reminders • Closing Teosha Harrison

Agenda

Thank You! We appreciate our provider

community and business partners for working together to improve

the lives of our members.