1. finance
2. personal finance
3. insurance
4. health insurance

TODAY'S PRESENTERS

Janne Denton
Contract Consultant & Specialty Provider Rep,
Institutional Relations, Blue Cross and Blue Shield of Kansas

Connie Winkley
Education Coordinator, Institutional Relations
Blue Cross and Blue Shield of Kansas

Brent Matile
Provider Program Specialist
Blue Cross and Blue Shield of Kansas

Marie Burdiek
Electronic Data Interchange (EDI) Account Representative
Blue Cross and Blue Shield of Kansas
AGENDA

Introduction

Institutional Relations Department

BCBSKS Website & Availity

Grace Period (Affordable Care Act)

Medicare Advantage

2015 Policies & Procedures & MAPs

Quality-Based Reimbursement Program (QBRP)

Electronic Data Interchange (EDI)
Who are we and
what do we do?
Institutional Relations (IR) Org Chart
Fred Palenske, Senior VP
Provider and Government Affairs
Dona Hewes
Administrative Coordinator, IR
Teresa Van Becelaere
Manager, IR
Angie Strecker, Director
Institutional Relations
Cindy Garrison, Provider Rep
Hospitals in Northern KS
Melanie Moriarty
Administrative Assistant (Topeka)
Connie Winkley
Education Coordinator
Janne Denton
Contract Consultant & Provider Rep
Katie Dennison
Claims Research Analyst
Brent Matile
Provider Program Specialist
Sally Stevens, Provider Rep
Hospitals in Southern KS
Kristi Donelan
Administrative Assistant (Wichita)
Institutional Relations Functions

IR Functions Include:
 Provider Contracts

Mailed annually in July
 Includes our Quality-Based Reimbursement Program (QBRP)
 Contracts with and services the following facilities:






Hospitals – CAH, PPS, Specialty, Limited Services, VA
ASCs
Home Health
Hospice
Dialysis Facilities
Skilled Nursing Facilities
 Education and Training







Workshops
Webinars
One-on-one provider visits
Training as requested
Newsletters and Manuals
eNews
Relevant Topics – i.e. ICD-10
Institutional Provider Relations

IR Functions include:
 Provider Claims Resolutions
 Katie Dennison – Claims Research Analyst
 Provider Representative
 Any IR staff member
 Provider Liaison Committees
 Solicit input from surgical groups – i.e. Optometrist, Audiologist, etc.
 Assist in the review and development of BCBSKS medical policies
BCBSKS Website
www.bcbsks.com
Public information includes:
 Medical Policies
 Forms
 ICD-10 Web page
 Precertification/Prior Authorization Information for Blue Plans
 Newsletters and Latest News (eNews)
 SOK & FEP web pages
Availity and BlueAccess

Availity (www.availity.com)




Availity Training




Single sign-on to Availity and BlueAccess
Eligibility & Benefits
Claims Status
Workshops
Webinars
Provider Visit
Availity to BlueAccess


Link through Payer Resources
Secure tools on BlueAccess include:





Remittance Advice
Member ID Look-up
Manuals
Some forms that can be sent electronically
QBRP Form
Affordable Care Act (ACA)
Grace Period

Exchange Individual Grace Period

ACA mandates a three-month grace period for those insured
through the Exchange who receive a subsidy.
 Individual has paid at least one month's premium
 The payer is only obligated to pay claims during the first month
 During the grace period, the payer may pend claims during the
second and third months
 Payer must notify HHS of non-payment of premiums
 Payer must notify provider of the possibility of denied claims
Affordable Care Act (ACA)
Grace Period
Marilyn Monroe
01/01/2000
ABC123456789
Female
123 Anystreet
Apt. 1
Anytown, KS 11111
08/14/2014
07/30/2014
04/01/2014 – 12/31/2014
9999999999
Affordable Care Act (ACA)
Grace Period
Rhett Butler
01/01/2000
ABC123456789
Male
Billy Butler
ABC123456789
123 Anystreet
Anytown, KS 11111
08/14/2014
07/30/2014
04/01/2014 – 12/31/2014
Medicare Advantage
•
Medicare Advantage (MA) facilitates the coordination of Blue Plan
Medicare Advantage claims and services for members and providers.
•
MA products must cover the same services as original Medicare Part
A/B and may include additional benefits.
•
MA has expanded to allow Plans to offer several types of MA products.
CMS Employer Group Waiver Guidance
•
Allows MA PPO and HMO groups to enroll members in areas where
provider networks do not exist.
Medicare Advantage
MA Private Fee-for-Service (MA PFFS)
•
Member may receive services from any Medicare provider that
accepts the Home Plan's terms and conditions.
Identifying a MA member:
Medicare Advantage
MA Claims Submission
• Submit all Medicare Advantage claims to BCBSKS
•
Do not bill Medicare directly for any services rendered to a
Medicare Advantage member
•
Payment will be made directly by a Blue Plan
•
MA claims cannot and will not be processed pursuant to
BCBSKS Policies and Procedures
•
Member's Plan is solely responsible for determining pricing
Medicare Advantage
MA Claims Submission
Home Plans need the following to adjudicate MA claims accurately and timely:
•
•
•
•
•
•
•
•
•
•
•
•
National Provider Identifier (NPI)
Source of Referral for Admission (one alpha-numeric character indicating
transfer or admission)
Core Based Statistical Area
Treatment Authorization Code
Admitting Diagnosis Code
Height and Weight for End-Stage Renal Disease (ESRD) patients
Ambulance Pick-Up Zip Code
HIPPS Code for Home Health, Skilled Nursing and Inpatient Rehabilitation
Taxonomy Code (if the provider represents an institutional with more than
one subpart to bill)
Certified Registered Nurse Anesthetists (CRNA) Special Code
Provider Service Location ZIP Code, if different than the billing ZIP Code
Present On Admission (POA) Indicator
Medicare Advantage
MA Appeals
• Reason for appeal may include:


A delay in providing, arranging for or approving healthcare services
The amount a member must pay for a service
•
Appeals can be submitted by
 Member
 Provider
 Assignee or the member's legal representative
•
Appeals submission:
 Submit to BCBSKS
 BCBSKS forwards to member's plan within 3 days of receipt
 Member's MA Plan will respond to provider within 30 days
•
•
•
Member's plan determines medical policy
Provider agrees to abide by final determination
Obtain appeals policies and procedures from the MA Plans
2015 Policies & Procedures
Updates and Changes:
• Language was added to the provider contracts that encompasses all
subsidiaries of BCBSKS

A new BCBSKS Subsidiary (a Health Maintenance Organization (HMO))
known as Blue Solutions will be sold to consumers soon with an effective
date of January 1, 2015:
o Blue Choice network
o Limited network with in-state contracting providers only
o Empty Suitcase
o Sold to individuals on and off the exchange and small group (SHOP)
markets
o Blue Solutions is not a traditional HMO:
 Members will not choose a Primary Care Provider (PCP)
 No referral is needed for visiting a specialty provider
 Members have open access through the BCBSKS Blue Choice
network
 Providers reimbursed using Blue Choice payment rates
2015 Policies & Procedures
Blue Solutions
The following alpha prefixes will be used for Blue Solutions members:
XSC - Individual Exchange Solutions
XSG - SHOP Exchange Solutions
XSQ - Individual Solutions Off-Exchange
XSR - Small Group Solutions Off-Exchange
2015 Policies & Procedures
Updates and Changes:
•
Language was added to specify a timeframe for organizing a First
Level Appeal Panel
•
BCBSKS has a credentialing program which:
 consists of an initial full review of the providers credentialing
application with re-credential at a minimum of every 36 months.
 monitors of all network providers for continual compliance with
established criteria will occur as needed, but not less than
monthly.
•
•
•
If a provider does not meet credentialing requirements, they will
not be allowed to participate as a network contracting provider.
Providers may appeal this decision by following the appeals
process outlined in the Policies and Procedures.
Credentialing Program requires BCBSKS to have an appeals panel
and BCBSKS will have 60 days from receipt of the appeal to organize
the appeals panel.
2015 Policies & Procedures
Updates and Changes:
• A section was added to the P&P to further define the confidentiality provision.
BCBSKS requires that all proprietary information be kept confidential. The
contracting provider may not disclose any terms of the Agreement to the third
party except upon written consent of BCBSKS and as required by state or
federal law.
• Added language to strongly encourage contracting providers to use the
Limited Patient Waiver (LPW).
 A waiver should be used for a variety of reasons included the service is
not medically necessary, the benefit is denied per the member contract or
the service is considered Experimental or Investigational.

Some providers have their own waivers and they may not meet BCBSKS
Requirements. If providers want to use your own waiver form to verify that
it includes everything that is on the BCBSKS waiver, then please have your
BCBSKS rep review your waiver form.
2015 Policies & Procedures
Updates and Changes:
•
A section was added outlining the administrative disputes
process to comply with health plan accreditation guidelines.
 This is not new; just clarification
 Provider may dispute issues of concern through their
BCBSKS Rep
 Rep will work with the provider to address the dispute
 Dispute may be escalated to BCBSKS management, if
unresolved
 BCBSKS will provide written response within 60 days of
management receiving the request
2015 MAPs
Code Changes
Based on additional information submitted by providers, the maximum allowable payments
(MAPs) for the following procedures will be increased in 2015 and additional codes will be
added in 2015.
ASC MAP'd Codes Increased for 2015
23410
25609
29863
23412
29807
29888
23455
29828
29914
25608
29862
29915
26619
ASC Codes Added in 2015
19020
23140
23145
23146
26500
26742
27455
29193
43280
53450
65091
65093
65103
67112
2015 MAPs
Payment attachment changes:
Page 6, Contract Amendments
A provision was added to amend the Contracting Provider Agreement
whereby BCBSKS could make adjustments to the maximum allowable
payment (MAP) for services.
"The Contracting Provider Agreement is hereby amended to delete
Section IV. B which references certain circumstances under which
BCBSKS could make adjustments to the maximum allowable payment
(MAP) for services. If the Contracting Provider has signed the Blue
Choice Agreement, then Section IV.3 is also amended."
Quality Based Reimbursement
Program (QBRP) Overview
Reporting periods
• Period 1 is due by November 15, 2014
• Period 2 is due by May 15, 2015
Effective dates
• Period 1 incentives will be effective January 1, 2015
• Period 2 incentives will be effective July 1, 2015
Data submissions
• Period 1 – attestations only
• Period 2 – data from all of CY 2014
Incentive increases
• Incentives earned will be applied to outpatient maximum
allowable payments (MAPs) and do not apply to services with a
charge below the MAP.
QBRP Prerequisites
• I attest that this facility will file all claims
electronically
• I attest that this facility will accept electronic
remittance advices
• Obtain eligibility, benefit and claim status
information primarily through electronic
transactions
Quality Measure 1 (QM1): Prophylactic Intravenous (IV)
Antibiotic Timing (CMS ASC-5)
Period 1:

Attest that this facility has a process in place to ensure that antibiotic
infusion is initiated within one hour prior to the time of the initial surgical
incision or the beginning of the procedure (e.g., introduction of
endoscope, insertion of needle, inflation of tourniquet) or two hours prior
if vancomycin or fluoroquinolones are administered.
Period 2:

Numerator: Number of ASC admissions with an order for a prophylactic
IV antibiotic for prevention of surgical site infections (SSI) who received
the prophylactic antibiotic on time

Denominator: All ASC admissions with a preoperative order for a
prophylactic IV antibiotic for prevention of surgical site infection
Incentive: 1.50%
Quality Measure 2 (QM2): Falls Within the ASC (CMS ASC-2)
For Period 1

Attest that a process is in place to capture any ASC admissions
experiencing a fall within the confines of the ASC.
For Period 2

Report the number of ASC admissions experiencing a fall within
the confines of the ASC.

Numerator: falls within the confines of the ASC in CY 2014

Denominator: all ASC admissions
Incentive: 1.00%
Quality Measure 3 (QM3): ASC Transfers to Hospital
Upon Discharge (CMS ASC-4)
For Period 1

Attest that a process is in place to capture any ASC admission
(patients) who are transferred or admitted to a hospital upon
discharge from the ASC.
For Period 2

Report ASC admissions who are transferred or admitted to a hospital
upon discharge from the ASC.

Numerator: ASC admissions requiring a hospital transfer or hospital
admission upon discharge from the ASC.

Denominator: all ASC admissions
Incentive: 1.50%
Quality Measure 4 (QM4): Surgical/Procedure Time Out

I attest that this ASC has a time-out protocol which requires a hard
stop by all after prep and drape and prior to the start of the
procedure. The protocol shall include the following:
a) identification of the patient by name
b) the procedure is stated
c) the marked incision site is visible
d) allergies are stated and share with the team and selected
prophylaxis antibiotics ordered and given
e) The team is asked about any concerns before starting.
Concerns are shared with the team and discussed to
mitigate risk.
Incentive: 0.50%
Form submission

Paper forms can be faxed to Brent Matile at 785-290-0734
or emailed to [email protected]

The QBRP form is available electronically

Any updates to contact information for Quality Managers
should be emailed or indicated on the paper form
Questions?