highmark blue cross blue shield wv may 15, 2014. health care exchange/ marketplace what is it? the...
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Highmark Blue Cross Blue Shield WV
May 15, 2014
HEALTH CARE EXCHANGE/ MARKETPLACE
WHAT IS IT?
The Affordable Care Act (ACA) requires that each state establish an online marketplace, referred to as a health insurance marketplace or exchange, through which qualified individuals may enroll in qualified health plan coverage. Eligible individuals that qualify for financial assistance to purchase coverage must purchase their coverage through a marketplace in order to receive the cost savings, which may include advance premium tax credit or cost-sharing reductions for those individuals who qualify.
The marketplaces, or exchanges, were scheduled to permit consumers in each state to begin the plan selection and enrollment process as early as October 1, 2013 for coverage that began January 1, 2014, the date when the individual coverage mandate became effective.
Health insurance marketplaces will support functions other than permitting qualified individuals to shop for qualified health plans. Consumers can also find out if they are eligible for public health programs such as Medicaid, and they can take steps to enroll in those programs.
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Health Care Exchange Products
Our Products & Formularies
ACA sets the requirements for Qualified Health Plans (QHPs) in terms of metal levels, out-of-pocket maximum limits, essential health benefits and more. Health plans on the exchanges are offered in a tiered format with several plans in each tier to choose from. Plan tiers are based on metal levels that match the percentage of costs covered (the actuarial value of the plan) as follows:
Bronze (60 percent) Silver (70 percent)Gold (80 percent) Platinum (90 percent)
Essential health benefits must be covered under each tier.•ambulatory patient services•emergency services •hospitalization•maternity and newborn care•mental health and substance use disorder services, including behavioral health treatment•prescription drugs•rehabilitative and habilitative services and devices•laboratory services•preventive and wellness services and chronic disease management•pediatric services, including oral and vision care
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Health Care Exchange Products
Helpful Tips……..
•No separate contract agreements to participate
•Follows Highmark WV Commercial Network Medical Policies Authorization process Management programs Services requiring authorization
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Cards will look the same as other lines of business for Highmark WV. Copays will be listed but not metallic tier.
NaviNet should be utilized to verify eligibility and covered benefits.
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Highmark Member Cards
How will this affect you and your provider….
THE 90-DAY GRACE PERIODThe Affordable Care Act (ACA) requires a 90-day premium delinquency grace period for individuals who purchased insurance through the Health Insurance Marketplace (HIM) and received an Advanced Premium Tax Credit (APTC).
Within this 30-day period, the member is placed in delinquency and the first delinquency letter is sent to the member. Claims are still being paid to providers at this point.
After 60 days with no premium payment(s) made, a second delinquency letter will be sent to the member, with the future termination date if payment is not made in full. Claim payment to providers is suspended at this point.
If 90 days pass and the account is not paid up to date, the member's coverage will be terminated and the claims rejected for payment back to the provider. Once a member's coverage is terminated for non-payment of premiums, he/she is responsible for claim payment to the provider.
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Alpha Prefixes Specific to Market Place Policies(subject to change)
ZPL-On Exchange
ZPI- Off Exchange
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PROVIDER RELATIONS REPRESENTATIVESSERVICING AREAS – January 1, 2014
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* Melanie Clyde and Joe Lippoli share Mon County – Melanie is responsible for WVU Hospital and connected Physicians as well as Mon General and connected physicians.
Highmark West Virginia website
www.highmarkbcbswv.com
• Resource Center
• Health Care Reform
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NETWORK PARTICIPATION
• The WVFH network is an extension of the Highmark BCBS WV PPO Network. Existing PPO providers who participate with Medicaid are offered participation with WVFH by agreeing to the amendment of the current agreement with Highmark WV
• Reimbursement for covered services is 105% of West Virginia Medicaid
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Primary Care Providers
Each West Virginia Family Health member will choose a Primary Care Practice as their Patient Centered Medical Home.
The PCP works in conjunction with the member to coordinate all appropriate medical care.
Members are able to change PCP’s on a monthly basis if requested.
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Referrals
In certain instances, members do not require a referral from the PCP to see a network specialty care practitioner.
Members may self refer for the following services:
• OB/GYN Services• Family Planning Services (Family Planning services do not have to be
rendered by a Network provider)• Dental services• Routine vision• Chiropractic services (an authorization must be obtained by the
chiropractic office, including the initial evaluation)• Mental health/substance abuse services
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Claims and Billing
• Bill all appropriate modifiers
• Bill all encounters, regardless of payment expected
• Timely filing Criteria₋ Initial Bills must be received within 12 month of date of service or payment from the
primary carrier.• All EPSDT claims and primary care services should be submitted within 60 calendar days from the date
of service to permit accurate member outreach.
₋ Corrected claims or requests for review must be received within 180 days from the date of the remittance advice
• Claims submitted with any attachments, such as EOBs from Primary Carriers must be submitted on paper
West Virginia Family Health – Claim DepartmentP.O. Box 69319
Harrisburg, Pa. 17106
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Electronic Billing
• Electronic claims accepted through Emdeon or Relay Health• Please refer to the following grid for Emdeon Payer ID’s and RelayHealth CPID’s
(clearinghouse Process ID):
• Hospital should include their West Virginia Family Health issued legacy number in your 837I submissions• Loop 2010BB REF01 with a qualifier of 'G2‘• REF02 should be WVFH Issued ID#
• PCP’s and Specialists should bill under their individual NPI#
CPID PAYER NAME PAYER ID CLAIM TYPE
45276 West Virginia Family Health (WVFH)
45276 Professional
45276 West Virginia Family Health (WVFH)
45276 institutional
Claims and Billing
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WVFH PROVIDER RELATIONS REPRESENTATIVESSERVICING AREAS - January 1, 2014
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Melissa [email protected]
Alana [email protected]
05 Brooke 04 Braxton15 Hancock 18 Jackson26 Marshall 07 Calhoun31 Monongalia 08 Clay
35 Ohio 11 Gilmer52 Wetzel 53 Wirt09 Doddridge 20 Kanawha02 Berkeley 54 Wood12 Grant 44 Roane
14 Hampshire 03 Boone16 Hardy 06 Cabell19 Jefferson 22 Lincoln29 Mineral 23 Logan33 Morgan 27 Mason36 Pendleton 30 Mingo
39 Preston 40 Putnam37 Pleasants 50 Wayne43 Ritchie 10 Fayette 48 Tyler 13 Greenbrier01 Barbour 24 McDowell
21 Lewis 28 Mercer25 Marion 32 Monroe17 Harrison 34 Nicholas42 Randolph 38 Pocahontas46 Taylor 41 Raleigh47 Tucker 45 Summers
49 Upshur 51 Webster 55 Wyoming
West Virginia Family Health Website
www.wvfh.com
•Policy & Procedure Manuals
•Complete Formularies
•Online Provider Directory
•WVFH Forms
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ATTENTION SKILLED NURSING HOMES
•Highmark has engaged the services of the Matrix Medical Network to help us complete health risk assessments for Medicare Advantage Plan beneficiaries
•There is no cost to the member
•Assessments help Highmark on-going commitment to quality care
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June 10th Charleston Marriott Salons A&C on the 2nd floor
June 11th Huntington Pullman Plaza Virginia/Maryland Rooms
June 17th Bridgeport Conference Center Ballroom
June 18th Wheeling Oglebay Conference Center Wilson Lodge Banquet Rooms 1, 2 and 3
Highmark WV Workshop Schedule
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FY 2015 Quality Blue Hospital Program FocusStreamlined to Six Components
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Measures included in the Quality Bundle: 20 CMS Star Measures
C01 Breast Cancer Screening C20Disease Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis
C02 Colorectal Cancer Screening C23Plan All-Cause Readmissions : Medicare Advantage
C03Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening
D11 Use of High Risk Medication in the Elderly
C04Comprehensive Diabetes Care: LDL-C-screening D12
Diabetes: Appropriate Treatment for Hypertension
C10 Adult BMI Assessment D13Medication Adherence for Diabetes Medication
C14Osteoporosis Management in Women who had a Fracture D14
Medication Adherence for Hypertension: Renin Angiotensin System Antagonists (RASA)
C15Comprehensive Diabetes Care: Eye exam ( retinal) performed D15
Medication Adherence for Cholesterol (Statins)
C16Comprehensive Diabetes Care : Medical attention for nephropathy C51
Annual Wellness and Initial Preventive Physical Exam Rate
C17Comprehensive Diabetes Care: HbA1c Control ( ≤9%) DMC 16
Pharmacotherapy Management of COPD Exacerbation: Systemic Corticosteroid within 14 days
C18Comprehensive Diabetes Care: LDL-C Control ( < 100 mg/dL) DMC17
Pharmacotherapy Management of COPD Exacerbation: Bronchodilator within 30 days
* Measures in blue denote Static measures
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Highmark WV Quality Blue Hospital Program Participants
Current Participants Future Participants
United Hospital CenterBerkeley Medical Center
Camden Clark Medical CenterJefferson Medical Center
West Virginia University HospitalMonongalia General
Fairmont GeneralLogan General
Cabell Huntington HospitalWeirton Medical Center
Wheeling Hospital
Bluefield Regional [FY2016]Thomas Memorial
St. FrancisGreenbrier Valley Medical
CenterPrincetonRaleigh
Pleasant Valley
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THANK YOU
Joyce Landers 304-347-7730 [email protected] Heiskell 304-347-7717 [email protected]
For questions or additional information please contact: