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2011 BLUE CROSS QUADRANT MEETING HANDOUTS

AUGUST 2011

AUGUST 2011

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2011 BCBSKS Quadrant Meeting Agenda 2012 Policies and Procedures Update

KHDS Hospital Abstracts

General Claims Issues

HealthCare Reform

ICD-10 / General Equivalence Mapping Tool Look-Up

BCBSKS Secure Online Access

Medical Policies

Pre-Certification

Medical Records Request

New Services

Off-Site Services

HIPAA 5010

TriWest/TRICARE

(Colby, Wichita and Topeka only)

Q & A

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2012 BCBSKS POLICIES & PROCEDURES FOR INSTITUTIONAL PROVIDERS

• Limited Patient Waiver

This document can be found online at: o www.bcbsks.com/providers/forms/limited patient

waiver

o This form replaces the Notice of Personal Financial Obligation (NOPFO)

• In the event that the provisions of BCBSKS publications,

policies and procedures, and/or the provider agreement conflict, the most recently published provision controls.

• Trim point definition clarified

o Length of stay less than “expected length of stay” is considered an inlier

• Defined expectation of specificity in coding submissions

o NOC and NOS codes will not be accepted upon implementation of ICD-10 coding

• Health Information Exchange (HIE) Participation o If the HIE is approved, contracting provider will be

required to provide data

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PAYMENT ATTACHMENT CHANGES FOR 2012

• Patient moved from higher to lower level of inpatient

care, expectation is that contracting provider will give patient a written Limited Patient Waiver prior to services being rendered.

• In the “Physician’s Orders” section, we replaced advanced registered nurse practitioner (ARNP) with advanced practice registered nurse (APRN).

• Reworded language regarding health fairs. It will make it easier for short-term events. It now reads: o If the contracting provider, through a short-term

promotion such as a health fair, offers services for a reduced price, BCBSKS members must also be offered the same services at the same price when provided at the short-term event.

• Reimbursement for items and procedures identified on the MAP list as an Add-On code will allow charges up to the MAP for that line item.

UB-04 Inpatient

Claim Form

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KANSAS HEALTH DATA SYSTEM (KHDS)

HOSPITAL ABSTRACTS

Kansas Health Data Systems is a unique department within Institutional Relations. KHDS is responsible for the processing of Medical Record abstracts and providing facility education to efficiently complete abstracts for all contracting hospitals in Kansas who submit inpatient claims. An abstract is a separate document, which must be present for BCBSKS inpatient claims to process completely. KHDS is a vital area of BCBSKS in which DRG validations and reimbursement audits have been made possible by efficiently transferring data through internally-developed systems.

KHDS Notes: • Hospital abstracts are designed to confirm the accuracy of the MS-DRG.

• Paid claims and abstracts are required to match.

• Audits done and adjustments are made when needed

Types of adjustments made by KHDS:

Have abstract and no claim

MS-DRG’s don’t match

Incorrect diagnosis or procedure code

Incomplete Present on Admission (POA) indicator

Incorrect admit or discharge dates

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• Abstracts are a contractual obligation

• Must be transmitted monthly (45 days from the end of each month)

• May’s data due July 15

• Each hospital will build their file from internal vendor or key in using My Ability or IVANS

• Option to send in BCBSKS data only or data for all payers

• KHDS facilitates sending in-patient data to Kansas Hospital Association for those facilities who submit all payer abstracts

KHDS Contacts: Deanna Karle, Manager, KHDS, 785-291-8702

Todd Colglazier, Health Information Systems Rep, 785-291-8830 Email KHDS - KHDS@BCBSKS.com

Watch for KHDS podcast coming in the near future!

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GENERAL CLAIMS ISSUES

• Multiple encounters (2 ER visits) same day = 2 claims o Make notation in Box 80 (remarks field if multiple visits)

• Multiple services same day:

o 2 chest x-rays = 1 line item with units of 2 and notation in Box 80

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• Observation (OBS)

o Report on one line and number of hours in units field o Reimbursed at 1 semi-private room rate or charges,

whichever is less o You must go by Provider’s orders o If Provider changes orders from in-patient to OBS, you

can charge OBS. We will still only pay one (1) semi-private room rate or charges, whichever is less

o Important to keep Room Rates up to date!

o 2 inhalation therapy treatments = 1 line item with units of 2 and notation in Box 80 and times of day patient came in

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HEALTH CARE REFORM

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Additional information on specific health care reform topics can be found on the BCBSKS website under the Topic Library link in the green box.

For a quick reference guide when submitting claims for preventative services, click here.

Additional information on Preventive Services covered under the Affordable Care Act is available on the bcbsks.com Web site. A complete list of Preventive Services Covered under the Affordable Care Act can be viewed at www.healthcare.gov.

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ICD-10 Mapping - General Equivalence Mapping (GEM) Look-up Tool

Log into BlueAccess and click on ICD-10 Mapping

1. Single Diagnosis Code Retrieval

WELCOME INSTITUTIONAL PROVIDER

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2. Diagnosis Code Range Retrieval (Choose by code and page number to retrieve GEM)

3. Description Look-Up

(Choose by code and page number to retrieve GEM)

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4. Single ICD-10 Diagnosis Code

5. Single ICD-10 Procedure Code

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BlueAccess - BCBSKS’s Current Secure Web site Access for Eligibility and Claim Status.

BCBSKS WEBSITE www.bcbsks.com

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The BCBSKS Web site www.bcbsks.com offers providers fast, easy access to a wide range of information including: Claim Status information* Eligibility Information* Remittance Advices* Newsletters Manuals Workshop Information Education Material Medical Policies ASK/EDI And More * Secured Access Required

As noted above, some of the information on our Web site is confidential and therefore, accessing it is a secure process. The secured section of the Web site is referred to as BlueAccess BlueAccess requires the user to create a “profile” during their first visit. Then on subsequent visits, the information established during the first visit is used to validate that the person has authorization to access the information. When you’re visiting www.bcbsks.com for the first time, our user-friendly instructions will assist you in establishing a secure profile. Non-confidential information such as provider publications can be accessed without establishing a provider profile. Claim status and eligibility information is also available for out-of-area (BlueCard) members. CREATING A USER PROFILE FOR BlueAccess Creating a user profile to access BlueAccess is easy to do.

From the home page, click on 'For Providers' under the Customer Service

tab.

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Once in the Provider section, click on the BlueAccess Sign-up.

The initial page will be the step-by-step instructions for establishing a user profile. In the BlueAccess box (as you see above) click on to Sign-Up. You will be signing up as a Provider. As you scroll to the bottom of the next page, you will see "Create your Secure Access". Click on that link to proceed. To initiate your user profile, you will be required to enter your facility's billing provider number (NPI) and tax identification number (EIN/TIN). Once you enter your facility's provider number, the screen will update to require you to select whether you are an institutional provider or a professional provider. Click the appropriate button.

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For security purposes, each individual should create their own user access. To do this, each individual should create their own user name, key in their first/last name, department within your facility and select and answer two challenge questions. The challenge questions will be used when you have forgotten your password and need to reset your password or when you need assistance in establishing access. For assistance in establishing access call 1-800-472-6481.

It is important when establishing the answers to your challenge questions, that the answer will be constant and not change over time.

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After the individual has created and submitted their user information, the system will generate a random password that will be mailed to the provider’s address via the U.S. Postal Service. YOU WILL NOT BE ABLE TO ENTER THE SECURED AREA UNTIL YOU HAVE RECEIVED AND ENTERED THE ORIGINAL PASSWORD SENT BY BLUE CROSS AND BLUE SHIELD OF KANSAS. This process takes generally 3-4 days. Once the password is received you will then be able to sign in to BlueAccess (Secured area) with this password. After you initially have logged into BlueAccess with the password you received from BCBSKS, it is recommended that you change the password. Each facility is responsible for monitoring who has access to BlueAccess and to notify BCBSKS when someone from your facility leaves. You can notify the Webmaster by clicking on Webmaster on the bottom of any bcbsks.com page who can remove any invalid user profiles.

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OTHER WEB RESOURCES

• There are many forms available for providers to use. Some forms can be completed and submitted online like: provider file updates, refund/deduct authorizations and claim enrollment inquiries.

• Other forms, like the Limited Patient Waiver require a signature so providers must either print a blank form and fill it out by hand or fill out the form online and print off to send to BCBSKS with the signature.

KEEPING CURRENT It is important for providers to keep up on the latest information and updates to the Web. To help keep informed, providers can sign-up for e-News, which is an e-mail notification system.

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Recent Changes to BCBSKS.com Benefit Inquiry Screens See BCBSKS Newsletter on the Web - Changes in the display of BlueAccess webpages

Due to the implementation of HIPAA 5010 on July 24, 2011, the manner in which a member’s eligibility and benefits are displayed on the Blue Cross and Blue Shield of Kansas BlueAccess Web site changed. These changes include:

• Benefit inquiries will now display the member name, patient name and relationship to the member, patient’s gender, and the member’s address.

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• Other Payer information will be displayed when applicable. • The policy’s benefit period will now be displayed on one line as the Date/Time

Qualifier. The policy’s original effective date will no longer be listed below the time period as required by HIPAA 5010

Format for the time period and effective date prior to July 24, 2011

Current format for the time period

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• The deductible and amount remaining will be displayed only one time (on a majority of inquiries) instead of showing under each service type listed in the benefit string. The deductible and amount remaining will be displayed at the beginning of the benefit information under service type Health Benefit Plan Coverage. The only time a deductible will be displayed under a specific service type is when the deductible for the service is different from the deductible listed below the Plan Coverage Description.

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• A new field - In Plan Network - was added to show whether or not a policy has in-network and out-of-network benefits.

• Service types that have the same benefits (i.e. same copay, visit limit, etc.) will be listed together.

• The coinsurance maximum and coinsurance maximum amount

remaining will now be displayed in the Additional Information below the coinsurance percentage benefit.

Please Note: When using the BlueAccess to retrieve member eligibility/benefit information you are encouraged to select the most specific Service Type that is available in the drop down box in order to receive the member’s eligibility/ benefit information in the most efficient manner.

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AVAILITY - BCBSKS Future Secure Web site Access for Eligibility and Claim Status effective January 1, 2012

What is Availity?

Availity offers a multi-payer portal at www.availity.com that gives physicians, hospitals and other health care providers secure access to multiple payers’ information through a single sign-on. Availity offers a variety of business and clinical solutions to help providers reduce administrative costs by eliminating paperwork and phone calls. Availity is one of the nation’s largest electronic health information networks, processing more than a billion transactions each year. Why is Blue Cross Blue Shield of Kansas teaming with Availity?

Our relationship with Availity will help remove costs from the system by streamlining transactions and processes. This will help reduce the amount of paperwork for medical practices, allowing physicians to spend more time with patients.

What are the advantages of using Availity? • No Charge – Health plan transactions are available at no charge to

providers.

• Accessibility – Availity functions are available 24 hours a day from any computer with Internet access.

• Standard responses – Availity returns responses from multiple payers in the same format and screen layout, providing users with a consistent look and feel.

• Commercial and Government Payers – Access to data from BCBSKS, Medicare, Medicaid and other commercial insurers. A full list of participating payers for each state by participation type is available at www.availity.com > Info for Providers > View Availity Health Plan Partners. The link to ‘View Availity Health Plan Partners’ can be found on the right hand side of the ‘Info for Providers’ page.

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• Compliance – Availity is compliant with the Health Insurance Portability and Accountability Act (HIPAA) regulations. Availity’s statement of compliance is available at www.availity.com. Select Info for Providers and then Regulatory Compliance. The link to Regulatory Compliance can be found on the right hand side of the Info for Providers page.

• Training – Availity offers free live and pre-recorded Web-based training seminars (webinars). Providers simply log into the Availity portal and register to attend the webinars of their choice. Demonstrations, frequently asked questions and comprehensive help topics are available online as well.

What services are available through Availity?

Providers can use the portal for the following BCBSKS member transactions: • Eligibility and Benefits • Claim Status • Claim Submission

Additional services and functions may be available from other payers. Who should providers call if they have questions about Availity?

Contact Availity Client Services toll free at 800-Availity (800-282-4548) or e-mail questions to support@availity.com. Availity Client Services is available Monday through Friday 8 a.m. to 7 p.m. ET (excludes holidays). For other assistance: • Availity Help

In Availity, click Help at the top of the page. Browse the books and topics as necessary

• Show Me Demos –

For a demonstration of many tasks available on Availity, go to www.availity.com, on the Home page under Availity Training and Resources, click Show Me Demos. Click any of the categories to expand them. Click a blue triangle to launch a demo.

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• Live and Pre-recorded Webinar Training

Availity offers live training conducted by phone and teleconferencing tools. To see the schedule and enroll: In Availity, click Free Training on any page. Click Live Webinar Schedule. To enroll, click a webinar title and follow the instructions on the page that displays.

If I already have access to BCBSKS’s web site, will I need to register to use the Availity® Health Information Network?

Yes. The Availity Health Information Network requires that you register and obtain a user ID and password. Once logged in to Availity’s network, you have the ability to transact with multiple health plans, eliminating the need to visit multiple sites and remember multiple passwords. What are the technical requirements?

All a provider needs to access Availity.com is:

• A computer with internet access. High speed is recommended for best results

• Microsoft Internet Explorer 6.0 or greater, which supports 128-bit encryption.

• A 1024 x 768 or greater pixel display for best results.

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Medical Policy

BCBSKS develops medical policies to assist providers or members to know the medical necessity criteria for certain services, or to determine if a service is considered experimental and investigational. State or Federal mandates and health plan member contract language, (including specific provisions/exclusions) take precedence over medical policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. Some of the BCBSKS policies are developed in collaboration with medical experts at the Blue Cross and Blue Shield Association. Others are developed after obtaining input from the BCBSKS 18 specialty Liaison Committees or other medical experts. In all cases, medical policy is reviewed by the BCBSKS Medical Policy Team to assure updates in processes, policies, and procedures meet the changing environment of medical technology. Policies are placed on the BCBSKS Web site and indicate the policy effective date. When revisions are made to the policy, the changes are noted in the policy revision section. Only the current policy is on the Web. If you need a previous version, contact your provider consultant for a copy. BCBSKS Medical Policy Web Page: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/index.htm When a patient does not meet the criteria in a policy, it is in the provider’s best interest to have the patient sign a Limited Patient’s Waiver (LPW) BEFORE the service is provided. With a signed waiver, if the service does not meet criteria, the charges will become patient’s responsibility. Without a signed waiver, the charges will be a provider write-off. As part of our Revenue Code Manual, we include links to medical policies that apply to various revenue codes. Our Revenue Code Manual has specific medical policy guidelines as well as billing guidelines applicable to BCBSKS. Providers our encouraged to use our confidential and proprietary manual when looking for claim filing information regarding BCBSKS members. This manual is located on the BCBSKS Web site in the secure section.

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To stay abreast of the latest changes and additions to the medical policies, providers are encouraged to sign up for e-News via the BCBSKS Web site at http://www.bcbsks.com/CustomerService/Providers/enews_institutional.htm

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As a reminder, medical policies for other Blue Plans are also available on the BCBSKS Web site at http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.htm As instructed on the Web page, you just need to key in the alpha prefix from the member’s card and click “GO”. See newsletter BC-10-14 for additional information.

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Precertification In June of 2010, a safety project was developed looking to improve inpatient certified suspensions. An increase of certified suspension was identified through the daily certified suspension report and through Provider Relations' claims. BCBSKS Institutional Provider Preventatives and Precertification staff set out to educate and train hospital staff on inpatient precertification in order to maintain a new goal of 5% or less of certified suspensions. Between October 2010 and January 2011, it was noted that providers were improving their certified suspension numbers after the provider education. Because of the positive reception to the precertification training by those performing the inpatient precertification we are proud to share the results for the first quarter of 2011:

January 2% February 4%

March 3% Because of this improvement and because the providers did an excellent job, the project was closed March 31, 2011.

NOTE: What are "unclosed precerts" (a.k.a certified suspensions)? Certified Suspensions are those precerts that do not satisfy the precertification process, the providers not providing "cradle to grave" information.

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Medical Records Request Before some claims can be processed, Blue Cross and Blue Shield of Kansas (BCBSKS) will request medical records in order to determine if medical necessity and/or criteria have been met. When BCBSKS makes such requests, the Contracting Provider will submit the requested information within 15 months of the date of service or discharge from the inpatient admission. Contracting Providers must also file Corrected Claims within 15 months of the date of service or discharge.

Sometimes the information being requested is not in any of the records at the facility. When this happens, it is up to the facility to obtain the essential documentation from the referring physician. Should the facility have difficulty obtaining the requested records from the ordering physician, the facility can contact their provider consultant for assistance.

If the ordering physician decides to send in the requested records directly to BCBSKS, they will need to include a copy of the medical request letter that was sent to the facility. This way, BCBSKS can match the records with the claim needing the information for processing. If BCBSKS cannot identify which claim needs the records, the records will be returned to the ordering physician.

BCBSKS will only request the necessary documentation once. We will make a decision on how to process the claim based on what records are received as a result of the request. If the records received do not support the medical necessity and/or criteria for the service, the claim will be denied. For more information see newsletter BC-10-17.

BlueCard record request are slightly different than a local member’s requests. BlueCard requests are faxed to the facility rather than a letter being sent by standard mail. The letter asks that the records be faxed to Staci Dick at 785-290-0768 within 5 business days. An example of a BlueCard Record Request letter is on the next page.

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Any Contracting Hospital Any town, KS 12345-6789

JOHN SMITH JANUARY 1, 1950

ABC123456789

0123456789 111111111111

January 1, 2011

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New or Expanded Services

The Contracting Provider agrees to notify BCBSKS of the addition of new services or the expansion of existing services. The purpose of this notification is to allow BCBSKS to determine if the new or expanded service is covered under the terms of the various member contracts

Off-Site Services

Services provided off-site of the physical presence of the main hospital campus must be billed on the CMS-1500 claim form, except in those cases where that off-site location is the sole place of service for an outpatient ancillary service or as determined by BCBSKS. When hospitals provide multiple services off-site of the main hospital campus, an addendum agreement to peer group pricing may be offered.

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Are You Ready for HIPAA 5010? On September 1, 2011 there will be 121 days to January 1, 2012 when the HIPAA 5010 Electronic Transactions are required! Blue Cross and Blue Shield of Kansas (BCBSKS) are taking action to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Version 5010 transaction standards. HIPAA requires all covered entities in the health care industry to implement and use mandated standards in the electronic transmission of health care transactions including claims, remittance, eligibility, claims status requests, their related responses and privacy and security standards. As you prepare for the implementation of HIPAA 5010, it is important to contact your vendors, clearinghouses, billing services or payers if they supply your software. They will provide detailed information on what steps your facility needs to take for a smooth transition. Here are some readiness questions that you should ask:

• Will HIPAA 5010 and ICD-10 software upgrades or changes be provided in one or multiple releases?

• What will be the cost of upgrades or changes to my practice? • When will upgrades or changes be available for testing? • When can I begin testing each transaction (e.g., 837 Claims, 835

Remittance Advice)? • Will I be required to test with each trading partner or payer? • What are the steps and time frame for completing a testing cycle? • Can 4010 and 5010 transactions be processed concurrently? • How will I know my implementation has been successfully completed? • Will my software support and convert the 277CA into a readable format? • What is my contingency plan if my systems are not compliant on Jan. 1,

2012?

For more information, visit the BCBSKS Web site at: http://www.bcbsks.com/CustomerService/Providers/edi/hipaa5010/index.htm or call Our EDI department at 1-800-472-6481, option 1 to check the status of your vendor testing.

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TRICARE Updates

Webmail Webmail is available from the TriWest secure provider portal at www.triwest.com/provider, registered providers can electronically submit claims-specific issues and other general website inquiries directly to TriWest Healthcare Alliance Corp. (TriWest) for resolution of TRICARE® West Region claims issues and inquiries with online claims correspondence/Webmail. For online claims correspondence, registered users are prompted to enter claims-related information (e.g., a beneficiary’s Social Security Number and/or claims number). Users also can electronically upload supporting documentation, if required, to process their claims inquiry, appeal or review. Webmail allows users to submit inquiries regarding general secure Web site topics (e.g., User Administration, Personal Profile, and Eligibility) that don’t necessarily require an immediate resolution. To learn how to correspond with TriWest regarding claims issues/inquiries and to access your secure account, visit www.triwest.com. You will be able to view the Online Claims Correspondence and Webmail Web site demonstration. To take advantage of these exciting new time-saving features, make sure you are registered for the secure provider portal at www.triwest.com/provider/registration.

Secure Web site Register for the secure Web site and have access to the following features:

• Patient Eligibility • Benefits • Referrals/Authorizations • Medical Review Requirements • Submit Claims • Claim Status • Webmail • Remittance Advices • Claims Status Reports

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Continue to Use Social Security Number Until further notice, providers should only use the sponsor's Social Security Number (SSN) in their web and EDI transactions with TriWest Healthcare Alliance (TriWest). This includes verifying eligibility, checking referral/authorization status, online claims submission and claims status.

The Department of Defense (DoD) announced in June that it will no longer issue military ID cards with an individual's SSN as an identifier. The SSNs will be replaced by two new numbers:

• DoD Identification Number (DoD EDI-PI or DoD ID) • DoD Benefits Number (DBN)

The DoD will issue new cards as individuals enlist or as a card expires. It is anticipated that there will be a four-year transition time to issue all new cards.

TriWest has discovered that due to a systems issue, we cannot accept the DoD ID or 11-digit DBN when submitted in a web or EDI transaction. A systems enhancement is scheduled for this fall.

We apologize for any inconvenience and thank you for your patience. Please watch the TRICARE eNews for updates.

Areas of Interest Available TriWest Healthcare Alliance's (TriWest) provider directory allows a user the ability to search and filter search results on provider areas of interest (AOI). AOIs are self-reported categories of practice focus that assist beneficiaries in making targeted decisions in selecting their provider. TriWest recently made AOIs available for medical/surgical providers, hospitals, skilled nursing facilities, durable medical equipment suppliers, radiology centers and urgent care centers. AOIs have been available for behavioral health providers. You should check the online TriWest provider directory at TriWest.com/provider to ensure your information is accurate. If your information needs to be updated or if you wish to submit your AOI so that it will display in the online provider directory, please contact your local TRICARE representative to submit your information or you can use the “Suggest-a-Change” functionality in the provider directory.

Adjustment Reason Code 835 Denials For many months now TriWest has been denying claims with adjustment reason code 835 in error. We have been advised that they implemented a fix in July. Providers do not need to resubmit claims, as TriWest will automatically locate claims denied erroneously and adjust them. These adjustments should be completed by Sept 1, 2011.