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HOSPITAL QUADRANT MEETINGSAUGUST 2015

Introduction Provider Certifications and Expanded Services Website Updates Other Party Liability (OPL) and Reconciling Accounts ICD-10 Edits VAPC3 and VACAA (Veterans Choice Program) 2016 Policies & Procedures Quality-Based Reimbursement Program (QBRP) Claims Pricing Q & A

AGENDA

Provider Certifications & 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.

BCBSKS tracks the following types of provider certifications and services:

• Diabetic Education• Lactation Consultant/Counseling• Blue Distinction Centers• Outpatient Pulmonary Rehabilitation• Cardiac Rehabilitation• Inpatient Hospice Programs• Sleep Studies• PET Scans


Diabetic Education• Outpatient diabetic education programs deemed appropriate for the

educational requirements necessary to promote self-education toward a safe-and-healthy lifestyle for diabetic members may be eligible for coverage.

• BCBSKS maintains a list and reimburses providers for diabetic education with one of the following: A program certified by the American Diabetes Association (ADA) A program certified by the American Association of Diabetes

Educators (AADE) Employs a Certified Diabetic Educator (CDE).

•Providers who are certified need to submit a copy of the certification to:BCBSKSInstitutional Relations, cc442D2 1133 SW Topeka BlvdTopeka, KS 66629-001Fax – 785-290-0734


Lactation Consultant/Counseling• Affordable Care Act (ACA) allows for coverage of these

services under policies that have preventive benefit services related to breast feeding education and coaching.

• Provide BCBSKS with a copy of the certification of the person performing the service received from either: Academy of Lactation Policy and Practice (ALPP) International Board of Certified Lactation Consultant (IBCLC)

• Providers who are certified need to submit a copy of the certification to:

BCBSKSInstitutional Relations, cc442D2 1133 SW Topeka BlvdTopeka, KS 66629-001Fax – 785-290-0734


Blue Distinction Center (BDC) Program The Blue Distinction Specialty Care Program is a national

designation program through the Blue Cross and Blue Shield Association and the local Blue Plan that recognizes healthcare facilities that demonstrate expertise in delivering quality specialty care — safely, effectively, and cost efficiently through two levels of designation:

• Blue Distinction Center (BDC) • Blue Distinction Center Plus (BDC+)

Only those facilities that first meet nationally established, objective quality measures for BDC (quality only) will be considered for designation as a BDC+ (quality and cost).


Blue Distinction Center (BDC) Program Blue Distinction Center and Blue Distinction Center+

designations recognize healthcare facilities delivering the following types of specialty care:

• Bariatric Surgery• Cardiac Care• Complex and Rare Cancers• Knee and Hip Replacement• Maternity Care -- Coming in 2016• Spine Surgery• Transplants


Blue Distinction Center (BDC) Program There are many benefits of becoming a Blue Distinction

Center or Blue Distinction Center+, including:• Differentiation in your community and beyond• Enhanced awareness and preference• Recognition among employers• Benchmarks provided to evaluate your performance against

your peers Please contact your BCBSKS Institutional Provider

Consultant for more details on BDC Programs. BDC information for providers can be found on the following

web page: http://www.bcbs.com/healthcare-partners/blue-distinction-for-providers/

http://www.bcbs.com/healthcare-partners/blue-distinction-for-providers/

http://www.bcbs.com/healthcare-partners/blue-distinction-for-providers/


Outpatient Pulmonary Rehabilitation BCBSKS offers coverage for pulmonary rehabilitation programs

and coverage is determined by:• the individual member’s contract• referral by their attending physician• BCBSKS Medical Policy – Outpatient Pulmonary Rehabilitation Program.

Providers should submit a detailed program description which must include:• A program schedule that includes date/times service is offered• A description of the services and equipment available• A description of the staff providing the services• A notation of physician availability• What criteria is used for patient assessment• A charge structure

http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/OutpatientPulmonaryRehabilitationPrograms_2013-07-12.pdf


Outpatient Pulmonary Rehabilitation BCBSKS must also receive a signed attestation certifying the

facility’s understanding and compliance with the criteria. Programs will normally be considered approved the first of the

month following receipt of the attestation and supporting documents.

Members will receive eligible benefits for pulmonary rehabilitation programs that begin on or after the approval date.

BCBSKS reimbursement is based on a maximum allowable payment (MAP) for each day of client participation. Detailed information on the Outpatient Pulmonary Rehabilitation

Program can be found in the BCBSKS Institutional Provider Manual on BlueAccess


Cardiac RehabilitationBCBSKS offers coverage for cardiac rehabilitation programs

and coverage is determined by:• The individual member’s contract• BCBSKS Medical Policy – Cardiac Rehabilitation Programs

Providers should submit a detailed program description which must include:• A program schedule that includes date/times the service is offered• A description of the services and equipment available• A description of the staff providing the services• A notation of physician availability• What criteria is used for patient assessment• A charge structure

http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/CardiacRehabilitationPrograms_2014-07-15.pdf


Cardiac Rehabilitation BCBSKS must also receive a signed attestation certifying the

facility’s understanding and compliance with the criteria. Programs will normally be considered approved the first of the

month following receipt of the attestation and supporting documents.

Members will receive eligible benefits for pulmonary rehabilitation programs that begin on or after the approval date.

Claims for cardiac rehabilitation should be submitted with Revenue Code 0943 and either CPT code 93797 or 93798 and report 1 unit for each day the patient participated in rehabilitation during the billing period. Detailed information on the Cardiac Rehabilitation Program can be

found in the BCBSKS Institutional Provider Manual on BlueAccess


Inpatient Hospice Inpatient hospice services provided in a skilled nursing facility, hospital or

other inpatient facility must be outlined and approved under the BCBSKS hospice inpatient program.

The allowance for approved inpatient hospice services will be 110% of the provider's Medicare inpatient hospice rate

Inpatient hospice services must be prior authorized The reimbursement guidelines for inpatient hospice services include:

• Services are provided in the skilled nursing facility, hospital or other inpatient facility approved under the hospice inpatient program.

• Members cannot be billed separately for room and board.• If the member has an inpatient skilled nursing facility benefit in

addition to their hospice benefit, only the hospice benefit will be payable when the member has elected hospice coverage.

• Revenue Code – 0656 – Inpatient Hospice Services


Inpatient Hospice If Total Parenteral Nutrition (TPN) is approved for an inpatient

hospice patient, then TPN is part of the inpatient hospice per diem and is not billed separately by the hospice provider.

Hospice providers are responsible for providing written notice to BCBSKS when their Medicare per diem rates are updated.

Rates can be sent to:BCBSKSInstitutional Relations Department, cc442D21133 SW Topeka Blvd.Topeka, KS 66629-0001Fax: 785-290-0734


Sleep Studies BCBSKS encourages sleep study facilities to become an accredited

sleep study facility. Contracting providers receive higher reimbursement if they are accredited, but providers who qualify for the highest level of reimbursement must notify BCBSKS in advance of billing claims. Proof of the accreditation must be submitted in order to receive proper reimbursement. BCBSKS recognizes the following accreditation for sleep studies:

• American Academy of Sleep Medicine (AASM)• Accreditation Commission for Health Care, Inc (ACHC)

When accreditation is received, send the information to:BCBSKSInstitutional Relations Department, cc442D21133 SW Topeka Blvd.Topeka, KS 66629-0001Fax: 785-290-0734


PET Scans Positron Emission Tomography (PET) Scans BCBSKS allowances include a tiered reimbursement for PET scans. The two levels of reimbursement for PET scans are based on whether the

provider has a fixed unit or uses a mobile unit. Providers with a fixed unit receive the highest allowance.

BCBSKS Institutional Relations Department needs to be notified the following information regarding this service:

• Type and model of fixed PET unit• Date fixed unit was installed• Revenue code 0404 must be used when billing PET Scans. A CPT

code is required when billing outpatient services Tracer codes are required for Pet Scans and may be separately billed.

Website Updates

New eNews for Institutional ProvidersComing January 1, 2016!

Website Updates

BCBSKS will be making some changes to their email notification system (eNews) effective January 1, 2016. The new eNews will make provider emails tailored and specific for the type of provider and their needs.

In order to make this change all email registrants will be required to re-register for the BCBSKS Institutional Provider eNews. The link to reconnect will be available between September 1 – December 31, 2015. The new email notification system will go into effect January 1, 2016. The current email groups will no longer be used after December 31, 2015. Don't miss out! Sign up at your first opportunity!

PLEASE SHARE THIS INFORMATION WITH YOUR CO-WORKERS AS ALL INSTITUTIONAL PROVIDERS WILL NEED TO RE-REGISTER FOR EMAIL NOTIFICATIONS!

Other Party Liability (OPL) and Reconciling Accounts

Avoid Delays• Both the OPL Questionnaire and the OPL Deduct Authorization

form can be found on the BCBSKS Website at: http://www.bcbsks.com/CustomerService/Providers/forms.htm

• Send or fax completed forms to the BCBSKS OPL department.

• Mail form to OPL at:Blue Cross and Blue Shield of Kansas Attn: OPL cc217D5 1133 SW Topeka Blvd Topeka, KS 66629-0001

• Providers can fax the form prior to submitting the claim to the OPL Department at (785) 291-0771

http://www.bcbsks.com/CustomerService/Providers/forms.htm


Determining Primary• BCBSKS follows NAIC and State Models to help us determine

where the primary payment responsibility lies when duplicate coverage exits. The most frequently used are: Subscriber Rule

Birthday Rule

Gender Rule

Divorce (Legal Separation) Rules

Retiree (or laid-off) Rule Consolidation Omnibus Budge Reconciliation Act of 1985 (COBRA)

Rule

Death Resulting in Remarriage Rule


Determining Primary• BCBSKS follows NAIC and State Models to help us determine

where the primary payment responsibility lies when duplicate coverage exits. The most frequently used are: Dumping Rule

Athletic Rule

Birthmother Rule

Adoptions Rule

Single mother with newborn Rule

Extension of Benefits (Senate Bill 23) Rule

Medicare and two group policies Rule

Longer Shorter Rule

Shared Payment (50/50) Rule


Reconciling Your Account• If the patient's responsibility, after the primary carrier's

payment, is greater than the BCBSKS allowance, then the provider must accept the BCBSKS write-off.


Reconciling Your Account The provider does not contract with the Primary Carrier , but does

contract with BCBSKS, then the BCBSKS allowance will be enforced.

• $500 is the patient responsibility because the provider does not contract with the primary payer

• BCBSKS allowance is $450 and the BCBSKS deductible is $450 • Since the member's responsibility of $500 is more than BCBSKS would

have paid, BCBSKS will pay $0 to the provider.

Example #1 Primary Carrier BCBSKS is secondaryCharge $500.00 $500.00Allowance $480.00 $450.00Deductible $480.00 $450.00Co-insurance N/A $0Payment (as Primary) $0.00Payment (as Secondary) $0


Reconciling Your Account Provider does not contract with the primary carrier, but does contract

with BCBSKS, then the BCBSKS allowance will be enforced.

• $500 is the patient responsibility because the provider does not contract with the primary payer

• BCBSKS payment: Allowance of $450 minus deductible of $100 = $350$350 - $70 (80% co-insurance) = $280

• Since the member’s responsibility of $500.00 is more than BCBSKS would have paid ($280.00), BCBSKS will pay $280.00 to the provider.

Example #2 Primary Carrier BCBSKS is secondaryCharge $500.00 $500.00Allowance $480.00 $450.00Deductible $480.00 $100.00Co-insurance N/A $70.00Payment (as Primary) $0.00Payment (as Secondary) $280.00


Reconciling Your Account• If the provider has a contracting agreement with both

carriers and the patient's remaining balance, after the primary carrier's payment, is greater than the BCBSKS total allowance, then the BCBSKS write-off is imposed.


Reconciling Your Account Provider does contract with the primary carrier and contracts with

BCBSKS, then the BCBSKS allowance will be enforced.

• Primary payer's allowance is $480.00 and the deductible is $480, which is the patient responsibility.

• BCBSKS’ allowance is $450 and the BCBSKS deductible is $450.• Since the member’s responsibility of $480.00 is more than BCBSKS would

have paid ($0), BCBSKS will pay $0 to the provider.

Example #3 Primary Carrier BCBSKS is secondaryCharge $500.00 $500.00Allowance $480.00 $450.00Deductible $480.00 $450.00Co-insurance $0Payment (as Primary) $0.00Payment (as Secondary) $0



BCBSKS, then the BCBSKS allowance will be enforced

• Primary payer's allowance is $480.00 and the deductible is $480, which is the patient responsibility.

• BCBSKS’ allowance is $450 - $100 deductible = $350 -$70 (80% co-insurance)= $280.00.

• The member’s responsibility of $480.00 is more than BCBSKS would have paid ($280.00), so BCBSKS will pay $280.00 to the provider.

.

Example #4 Primary Carrier BCBSKS is secondaryCharge $500.00 $500.00Allowance $480.00 $450.00Deductible $480.00 $100.00Co-insurance $70.00Payment (as Primary) $0.00Payment (as Secondary) $280.00


Reconciling Your Account• If the provider has a contracting agreement with both

carriers and the patient's remaining balance, after the primary carrier's payment, is equal to or less than the BCBSKS total allowance, then the primary write-off is imposed.



BCBSKS, then the BCBSKS allowance will be enforced.

• Primary payer's allowance is $480.00. The deductible is $250.00 and the co-insurance is $46.00; therefore, $296.00 is the patient responsibility.

• BCBSKS’ allowance is $450 - $100 (deductible) = $350 - 70 (80% co-insurance)= $280

• Since the member’s responsibility of $296 is more than BCBSKS would have paid ($280), BCBSKS will pay $280.00 to the provider.

Example # 5 Primary Carrier BCBSKS is secondaryCharge $500.00 $500.00Allowance $480.00 $450.00Deductible $250.00 $100.00Co-insurance $46.00 $70.00Payment (as Primary) $184.00Payment (as Secondary) $280.00

ICD-10 Edits

The following edit will be implemented for BCBSKS only and will begin with the acceptance of ICD-10-CM coding on 10/1/2015.

Unspecified Laterality•PURPOSE: EDI front end edits for Professional and

Institutional claims will be implemented to encourage providers to document and specify the most appropriate code related to a condition. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the right, left, or is bilateral.

• Accurate coding allows BCBSKS to administer policy benefits in an efficient and effective manner.

•Detailed edit logic information can be found on the ASK website: http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-laterality.pdf

http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-laterality.pdf

http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-laterality.pdf

ICD-10 EDITS

The following edit will be implemented for BCBSKS only, and will begin with the acceptance of ICD-10-CM coding on 10/1/2015.

Unspecified Trimester – BCBSKS Only; Inpatient Claims Only• PURPOSE: EDI front end edits for Institutional Inpatient

claims will be implemented to encourage providers to document and specify the most appropriate code related to a condition.


• Detailed edit logic information can be found on the ASK website: http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-trimester.pdf

http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-trimester.pdf

http://www.ask-edi.com/pdf-docs/ICD-10-edit-notification-trimester.pdf

ICD-10 EDITS

The following edit will be implemented for BCBSKS only, and will begin with the acceptance of ICD-10-CM/PCS coding on 10/1/2015.

Unacceptable Principal Diagnosis• PURPOSE: EDI front end edits for Institutional Inpatient claims will be

implemented to encourage providers to document and specify the most appropriate code related to a condition. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."


• Unacceptable Principal Diagnosis Codes can be found at the Definition of Medicare Code Edits on the following web page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

Coming in 2016 – Duplicate Diagnosis Edits

http://www.cms.gov/Medicare/Coding/ICD10/downloads/icd10_mce27_user_manual.pdf

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-Definitions-of-Medicare-Code-Edits-V32.zip

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending




ICD-10 EDITS / Frequently Asked Questions (FAQs)

Will there be changes to the pre-authorization process?• No, the process for Precertification will not be changing

When will you accept ICD-10 pre-authorization request for services provided on and after October 1,2015?• Precertification will be able to accept request for October 1, 2015 or

after beginning on July 1, 2015. Will pre-authorization submitted before 10/1/15 that use ICD-9 codes

work for ICD-10 claims?• Yes

What happens if I do not switch to ICD-10?• Claims for all services and hospital inpatient procedures provided on

or after October 1, 2015 must use ICD-10 diagnosis and inpatient procedures (this does not apply to CPT coding for outpatient procedures). Claims that do not use ICD-10 diagnosis and inpatient procedures codes cannot be processed. It is important to note, however, that claims for services and inpatient procedures provided before October 1, 2015 must use ICD-9 codes even if they are submitted after the compliance date.

ICD-10 EDITS / FAQs After October 1, 2015, how long will BCBSKS continue to process claims

submitted in ICD-9 with a date of service before the code change?• BCBSKS will continue to accept ICD-9 codes after October 1, 2015 as

long as the date of discharge or date of service is before October 1, 2015. Timely filing requirements are not impacted by ICD-10.

For claims with dates of service October 1, 2015 and after, what ICD code set (ICD-9 or ICD-10) will BCBSKS be accepting?

• BCBSKS will only accept ICD-10-CM/PCS on or after date of discharge or date of service of October 1, 2015.

Will BCBSKS allow both ICD-9 and ICD-10 codes on the same claim?• No. Use ICD-9 codes for date of service and date of discharge before

October 1, 2015, and use ICD-10 codes for date of service and date of discharge after October 1, 2015.

Will BCBSKS allow ICD-9 and ICD-10 codes in the same BATCH claim file?• Yes. However, once we accept the batch, claims are reviewed at the

claim level, and we will stop claims that have a mix of ICD9 and ICD-10 codes.

VAPC3 and VACAA (Veterans Choice Program)

September 4, 2013 - the VA awarded TriWest HealthCare Alliance (TriWest) a contract to administer the Patient-Centered Community Care (VAPC3). August 7, 2014 - President signed into law the Veterans

Access, Choice, and Accountability Act of 2014 (Choice Act), which established the Veterans Choice Program.

TriWest Healthcare Alliance partnered with Veterans Affairs (VA) to administer the VAPC3 and Choice Card Programs in Regions 3, 5, and 6.

Most counties in Kansas are located in Region 3, however, Cheyenne, Sherman, Wallace, Logan, Greeley, Hamilton, Stanton, Norton, Phillips, Smith, Jewel, and Washington are considered part of Region 4.


VAPC3 Overview• The program only covers care referred to TriWest that

can't be provided by a VA provider/facility.• The program only covers Veterans enrolled into the VA

Healthcare System. • Program includes primary care, specialty care, ancillary

care, ambulatory surgery and inpatient care.• All Veteran eligibility is determined by VA.• Prescriptions will be filled by VA except for an initial

emergency ten (10) day supply.


VAPC3 Appointment Scheduling Process:• TriWest receives an authorization request from a VA for

services for a Veteran • A TriWest Patient Services Representative (PSR) will locate a

network provider to assist with scheduling an appointment. • The PSR will give both the Veteran and the provider the authorization

number. • Provider can also access TriWest’s secure Provider Portal at

www.triwest.com/vapccc/provider, to print out the authorization that contains the Veteran’s authorization number, the units authorized, the date range of the authorization and the Current Procedural Terminology (CPT) codes approved for the episode of care.

• TriWest has the authority to make the appointment on behalf of the Veteran

• Services provided to a Veteran without authorization from TriWest will not be paid under the VAPC3 program.

http://www.triwest.com/vapccc/provider


Veterans Choice Program Overview• The Veteran Choice Program (VCP) is the newest addition to

the Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) program.

• VCP provides eligible Veterans with access to primary care, inpatient and outpatient specialty services, and behavioral health care.

• All Veterans enrolled for care with VA as of August 1, 2014 received a Choice Card.


Veterans Choice Program Overview The Veteran’s eligibility to use VCP in the private sector is

determined by the VA under the outlined criteria: • The closest VA Medical Center (VAMC) or Community Based

Outpatient Clinic (CBOC) is greater than 40 miles from their home; or • If they have been on a wait list for 30 days of more with a VAMC

If a Veteran would like to make an appointment, refer them to the number on the back of their card.


VAPC3 and VCA ComparisonsVAPC3 Program Veterans Choice Program

Plan Description

A program designed to enhance access to health care by allowing VA Medical Centers to refer Veterans to a quality provider network closer to a Veteran’s home

A program for Veterans that provides a Veterans Choice Card that allows them to seek care from community providers if the Veteran faces wait times longer than 30 days for a specific service from a VA Medical Center or when a VA medical facility is not easily accessible (>40 miles) from their home

Referrals The VA Medical Center sends a care request to TriWest and the network provider subsequently receives an authorization for care from TriWest.

• Provider receives authorization for care from TriWest.

• For those Veterans who are eligible because they are on a 30-day wait list, provider will also receive clinical/consult information from a VA Medical Center.

• For those Veterans who are eligible due to the fact that a VA medical facility is not easily accessible (>40 miles) from their homes, only the TriWestauthorization is provided.



Other Health Insurance

Other Health Insurance (OHI) is not relevant.

TriWest will notify the provider if Commercial/private OHI should be billed. If notified, private health insurance is the primary payor

Co-Pays No copayments. All allowable charges are paid by TriWest

If commercial OHI is present, provider should follow the copayment requirements of the OHI carrier.

Claims Submission

Claims submitted to WPS

Claims submitted to WPS



Secondary Authorizations

Separate authorizations must be requested from TriWest for any services beyond what has been authorized.

Separate authorizations must be requested from TriWest for any services beyond what has been authorized.

Medical Documentation

Medical documentation must be returned to TriWestprior to payment of any claim

Medical documentation must be returned to TriWest prior to payment of any claim


Additional information regarding VAPC3 and Veterans Choice Program

www.triwest.com/vapccc/provider• Quick reference guides• Claims submission/processing information• Provider handbook• Webinars/Eseminars• Forms• Resources

http://www.triwest.com/vapccc/provider

2016 Policies & Procedures Updates and Changes

Updated language for clarity and consistency• The purpose of these Policies and Procedures is to provide

specific explanations of provisions contained within the Contracting Provider Agreement [effective January 1, 2015. They apply to services provided in the Blue Cross and Blue Shield of Kansas (BCBSKS) service area as defined by the Blue Cross and Blue Shield Association]. This information is intended to supplement and further clarify the reciprocal rights and contractual obligations contained within the contract and the policies established by Blue Cross and Blue Shield of Kansas, Inc. (BCBSKS) when services are provided in our service area (the state of Kansas not including Johnson and Wyandotte counties).


Further defined the following term• Section – Definitions, Competitive Allowance Program ("CAP")

The Blue Cross and Blue Shield of Kansas Competitive Allowance Program ("CAP") is the reimbursement agreement between BCBSKS and providers of health care services for traditional benefit programs.


Added the following definition for Intensive Outpatient Program (IOP) and clarified the definition and changed the name of term Partial-Day Treatment to Partial Hospitalization Program (PHP)• Section – Definitions, Intensive Outpatient Program ("IOP") &

Partial Day Intensive Outpatient Program ("IOP") is an intensive outpatient

individual and / or group treatment program designed to achieve short-term stabilization and resolution of immediate mental health problem areas.

Partial Hospitalization Programs ("PHP") is a type of program used to treat mental illness and substance abuse. In PHP, the patient continues to reside at home, but commutes to a treatment center up to seven days a week. Partial Hospitalization focuses on the overall treatment of the individual, and is intended to avert or reduce in-patient hospitalization.


Added language to clarify the credentialing program and to further define provider appeal rights.

• Section – General Conditions, Credentialing BCBSKS follows URAC guidelines for credentialing and has a

[credentialing] program that consists of an initial full review of the applicable providers credentialing application. Contracting Providers, including acute inpatient facilities, freestanding surgical centers and home health agencies, are [with] re-credentialed [occurring] at a minimum of every 36 months. Monitoring of all Contracting Providers for continual compliance with established criteria will occur as needed and at least monthly. If applicants do not meet all applicable credentialing criteria, the

applicant is ineligible to be considered by the Corporate Credentials Committee. The reconsideration and appeal process described below will not be available to such provider. If the provider ceases to comply with criteria or has an adverse action

taken by the licensing board, credentialing staff will review such adverse action or failure to comply and report to the Committee.


Credentialing criteria are available on the BCBSKS Website at www.bcbsks.com.

If a Contracting Provider is currently subject to any sanctions imposed by any CMS program or by the Federal Employee Health Benefit Program, including but not limited to being excluded, suspended, or otherwise ineligible to participate in any state or federal healthcare program, the reconsideration and appeal process described below will not be available to such provider.

NOTE: If a Contracting Provider's license is suspended or revoked, that provider's BCBSKS network contract is canceled by operation of the terms of the contract. When credentialing staff members become aware of such suspension or revocation, they shall notify the Committee, but the Committee is not required to take any specific action since the provider's contract will terminate of its own accord. Credentialing staff shall also notify the institutional relations operations division of such suspension or revocation to ensure that appropriate administrative action is taken.

http://www.bcbsks.com/


Section – General Conditions, Timely Filing Contracting Providers must also file Corrected Claims within

15 months of the date of service or discharge. At times, additional information or clarification is needed to accurately adjudicate claims. 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. Claims denied requesting additional information (e.g. by letter or adjustment reason code) should never be marked "corrected claim" when resubmitted. Instead providers should submit a new claim with the requested information.

2016 Quality-Based Reimbursement Program (QBRP)

Quality-Based Reimbursement Program (QBRP) What is it?

• Rewards providers for superior quality outcomes• Provides incentive for efforts to enhance quality of care• BCBSKS works with providers to select meaningful

quality measures• Prerequisites must be met to participate in QBRP

QBRP Prerequisites include: Attest that hospital accepts electronic remittance advice

• Either ANSI 835 or from the BCBSKS secure website

Attest that the hospital will use the BCBSKS electronic portal for IP hospital precertification and continued stay reviews

• Threshold for both precertification and continued stay review must be met to earn incentive for this measure

Hospital will obtain eligibility, benefit and claim status information primarily through electronic transactions

• Availity interface (eligibility & benefits, claim status)• ANSI 270/271 transaction (eligibility)• ANSI 276/277 transaction (claim status)

2016 QBRP

2016 QBRP

2016 QBRP semi-annual reporting dates November 5, 2015 for January 1, 2016 effective date May 5, 2016 for July 1, 2016 effective date Reporting results will be mailed to providers within 30 days

of reporting deadline

Quality incentive will apply to 2016 inpatient MS-DRG MAPs, per diems, and outpatient MAPs, except for reference laboratory and pharmacy.

Electronic Precertification and Continued Stay Reviews (CSR) Period 1

• Based on Electronic Precert & CSR submitted between May 1, 2015 through October 31, 2015

Period 2• Based on Electronic Precert & CSR submitted between

November 1, 2015 through April 30, 2016 No data will need to be submitted by your facility for this

measure. BCBSKS will monitor and track internally.

2016 QBRP

General Claim Reminders

GA Modifier – No Paper! Code to the greatest specificity Electronic claims typically paid within 14 working days Timely filing = 15 months

• BlueCard and self-funded groups may have alternative timely-filing requirements

Remittance Advice gives claims detail information• Use Availity to check claim status!

BCBSKS Inpatient Claims Discounts

• CAP, Blue Choice and Value Blue, etc. Incentive payment Reimbursement made by date of discharge Interim billing

• Katie Dennison – Claims Research Analyst [email protected] claims questions contact Katie at 785-291-8849Fax claims to Katie at 785-291-0734

Discharge and readmission on the same day Room and board charge not medically necessary Skilled Inpatient Care

mailto:[email protected]

Inpatient Maximum Allowable Payment (MAP) EXAMPLE ONLY

Claims Pricing Reimbursement

DRGCode

DRG Description 2015 Map Low Count High Count

0411 CHOLECYSTECTOMY W C.D.E. W MCC $24,495.00 2 70412 CHOLECYSTECTOMY W C.D.E. W CC $33,592.00 2 70413 CHOLECYSTECTOMY W C.D.E. W/O CC/MCC $21,661.00 1 50414 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC $1,532.00 2 100415 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC $1,796.00 2 100416 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC $15,514.00 1 30417 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC $112,560.00 2 60418 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC $101,593.00 1 50419 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC $2,367.00 1 40420 HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC $1,314.00 2 80421 HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC $270.00 2 60422 HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC $75,552.00 2 50423 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC $35,789.00 2 60424 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC $33,998.00 2 50425 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC $1,288.00 1 50432 CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC $2,366.00 2 120433 CIRRHOSIS & ALCOHOLIC HEPATITIS W CC $2,398.00 2 90434 CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC $15,327.00 2 90435 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC $35,331.00 2 70436 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC $22,758.00 2 70437 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC $75,478.00 1 40438 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC $87,270.00 1 40439 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC $58,429.00 1 4

Inpatient Admission – Blue Choice (Example Only)• Admission/Discharge Date: 06/04/15 – 06/07/15 (3 days)

• Contract Type: Blue Choice (BC)

• MS-DRG Assigned: 0470

• MS-DRG MAP: $2,339.00 (example only)

• Total Charge: $3,176.60

• Quality Based Reimbursement: 3.75%

• Incentive Rate: 21%

• High Trim Days: 5

• Per Diem Add-on for Days above High Trim: Not Applicable



The calculation is:Step 1 – Calculate QBRP Incentive

MS-DRG MAP $2,339.00QBRP (3.75%) (multiply by .0375 and add) + 87.71

$2,426.71Step 2 – Calculate Inpatient Incentive

Claim's Total Charge $3,176.60MAP with QBRP Applied (subtract) - 2,426.71

$ 749.89Inpt Incentive (21%) (multiply) x .21

$ 157.48

Step 3 – Calculate Contractual DiscountMAP with QBRP Applied $2,426.71BC Disc (5%) (multiply by .05 and subtract) - 121.33

$2,305.38

Step 4 – Blue Choice Disc $2,305.38Inpt Incentive (add) + 157.48New Blue Choice MAP $2,462.86

Inpatient Admission – CAP – Length of Stay Exceeds High Trim Days (Example Only)• Admission/Discharge Date: 06/04/15 – 06/14/15 (10 days)• Contract Type: CAP• MS-DRG Assigned: 0470• MS-DRG MAP: $22,915.00 (Example only)• Total Charge: $60,209.06• Quality Based Reimbursement (QBRP): 3.75%• Incentive Rate: 7%• High Trim Days: 6• Per Diem Add-on for Days Above High Trim: Days of admission 10 High trim days (subtract) -6 Days above high trim 4

To determine the per diem add-on, divide the MS-DRG by the number of high trim days assigned to this MS-DRG. In this example: MS-DRG MAP 22,915.00 divided by 6 = 3,819.17. This is the daily per diem add-on. The total per diem add-on for the 4 days above the high trim days would be:3,819.17 X 4 = $15,276.68


Step 1 – Determine New CAP MAPMS-DRG MAP $22,915.00Per Diem Add-on (add) $15,276.68New MS-DRG MAP $38,191.68

Step 2 – Calculate QBRPNew MS-DRG MAP $38,191.68QBRP - 3.75% (multiply by .0375 and add) $ 1,432.19New MS-DRG MAP plus QBRP incentive $39,623.87

Step 3 – Calculate Inpatient Incentive:Claim's Total Charge $60,209.06New MS-DRG MAP plus QBRP Incentive(subtract) -39,623.87

$20,585.19Inpt Incentive (7%) (multiply) x .07

$ 1,440.96Step 4 – Calculate Contractual Discount - No CAP contractual discount since MS-DRG is MAP'd

Step 5 – Calculate Final CAP MAP:QBRP Rate $39,623.87Inpt Incentive (add) + 1,440.96New CAP MAP $41,064.83


OUTPATIENT CLAIMS PRICING

Know your contractual discounts

Know where your MAP listings are located

Outpatient MAP Listing – EXAMPLE ONLY

CLAIMS PRICING REIMBURSEMENT

Code Nomenclature 2013 MAP Unit Limit

Add OnCode

Claim LevelCode

Newly AddedCode

0019T EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCULOSKELETAL SYSTEM, NOT OTHERWISE SPECIF

$2,182.00 X

0510 CLINIC - GENERAL CLASSIFICATION $110.52 1.000683 TRAUMA RESPONSE - LEVEL III $10.67 1.000762 TREATMENT OR OBSERVATION ROOM - OBSERVATION ROOM $453.75 1.000102T EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A PHYSICIAN, REQUIRING ANES $218.00 X

10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTAN $1,507.00 X

10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTAN $1,507.00 X

10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE $1,507.00 X10081 INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED $53.75 X10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE $1,507.00 X10121 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED $1,507.00 X10140 INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION $1,507.00 X10160 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST $1,507.00 X10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION $1,507.00 X11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE $76.50 X

11010 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTUR $76.50 X



11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); $76.50 X

11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS $153.75 X

11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/O $153.75 X

11045 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); $153.75 X

11046 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS $153.75 X

11047 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/O $153.75 X

PRICING A "CLAIM LEVEL" CLAIMStep 1: Determine if this is a claim level code

Step 2: Is the claim due to an accident or injury? Revenue Code 450 Occurrence Code 1–6 Does service date and accident date match?

Step 3: Look for Revenue Code 450 and/or 762 Are there lab codes?

• If yes, then non-MAP'd and discount off charge• Revenue Code 762 – one average semi-private room rate

PRICING A "CLAIM LEVEL" CLAIM

Step 4: Add-Ons Additional reimbursement

Step 5: Quality-Based Reimbursement Program (QBRP) Stacked calculation

• % earned for each QBRP measure

Add sum to original CAP MAP

Step 6: Apply contractual discounts, if applicable

PRICING A "LINE LEVEL" CLAIMStep 1: Determine if claim is priced at the line level

Step 2: Price each line separately

Step 3: If no MAP, then line is allowed at discount off charges

Step 4: QBRP Stacked calculation

• % earned for each QBRP measure Add sum to original CAP MAP

Step 5: Apply contractual discount, if applicable


Outpatient – CAP – Reference Laboratory Services – Fee Schedule Contract Type: CAP QBRP: N/A Outpatient Discount: 0% (example only)

Fee Schedule: Varies – see hospital MAP listing Does Fee Schedule Apply?

• Yes, if revenue code 045X or 0762 does not appear on the same claim.

• No, if billed in conjunction with revenue code 045X or 0762. If a fee schedule does not apply, the allowance is charge less discount.


HCPCS/CPTDoes this code appear

on the lab fee schedule? Allowance36415 Yes Fee schedule or charge

whichever is less84153 Yes Fee schedule or charge

whichever is less

Claim does not include either Revenue Code 045x OR 0762(Example only)

NOTE: Reference laboratory services do not qualify for QBRP.

HCPCS/CPT Charge Fee Schedule Allowance36415 11.00 7.50 7.50

Apply QBRP Incentive (3.75%) X .03757.78

84153 57.00 51.50 51.50TOTALS 68.00 59.00 59.28

CLAIMS PRICING REIMBURSEMENTOutpatient – CAP – No CAP MAP Involved (Example only)

NOTE: Since 99281 is not MAP’d, QBRP does not apply. Referencelaboratory and revenue code 250 services do not qualify for QBRP.

Revenue Code

HCPCS/CPT Charge Is there a MAP? Allowance

0250 N/A 80.22 No 80.22

Apply Discount (10%) X .9072.20

0300 81015 15.00 NO, revenue code 0450 is billed on the same claim. 15.00


0450 99281 105.00 NO 105.00


TOTALS 200.22 180.20

Contract Type: CAPQBRP: N/AOutpatient Discount: 10% (example only)


Outpatient – CAP – MAP’d Surgery – No add-on services(Example Only)

• Contract Type: CAP • QBRP: 4% (example only)• Outpatient Discount: NA (example only) • Services: This claim is for outpatient surgery and is priced at claim

level NOTE: Only the surgery code qualifies for QBRP (example only).

When reviewing your RA, you will notice that all the lines have a MAP allowance. This is not actually the MAP for that line, but rather a part of the surgery MAP that has been allocated across each claim line in proportion to the line charge.


Revenue Code HCPCS/CPT Charge Add-on Code? Allowance

0250 NA 100.55 NO Included in Surgery MAP

0258 N/A 97.65 NO Included in Surgery MAP


0300 83045 11.00 NO Included in Surgery MAP



0360 49650 2430.00 NO 2008.00

Apply QBRP and Outpatient Discount: Allowance 2008.00

Apply QBRP Incentive (4%) + 80.32

New Allowance with QBRP applied 2088.32

0370 N/A 275.75 NO Included in surgery MAP




TOTALS 3927.05 2088.32


Outpatient – Blue Choice – MAP’d Surgery – With add-on services(Example Only)

Contract Type: Blue Choice QBRP: 4% (example only) Outpatient Discount: 15% (example only) Services: This claim is for outpatient surgery and is

priced at claim level with add-on services.

NOTE: The CT and surgery qualify for QBRP (example only)When reviewing your RA, you will notice that all the lines have a MAP allowance. This is not actually the MAP for that line, but rather a part of the surgery MAP that has been allocated across each claim line in proportion to the line charge.



0250 NA 00.55 NO Included in Surgery MAP






0352 71260 810.00 YES

Allowance in addition to MAP'd Surgery

750.00

Apply QBRP and Outpatient Discount: Apply QBRP Incentive (4%) + 30.00

New Allowance with QBRP applied 780.00

Apply Blue Choice Discount (15%): x .85

New Allowance with QBRP and Blue Choice Discount : $663.00


0360 49650 2430.00 NO 2008.00

Apply QBRP and Blue Choice Discount

MAP 2008.00

Apply QBRP of 4%: X .04

QBRP Amount: + 80.32

MAP with QBRP 2088.32

Apply BC Discount (15%) x .85

New Allowance with QBRP and BC Discount Applied: 1775.07

0370 N/A 275.75 NO Included in MAP'd Surgery

0460 94010 5.00 NO Included in MAP'd Surgery

0636 Q9949 364.19 YES

Allowance in addition to MAP'd Surgery: 225.00

Apply BC Outpatient discount (15%) to MAP: x .85

New MAP with Blue Choice Discount Applied: 191.25



TOTALS 5101.94 2629.32


Outpatient – Blue Choice – ER with Observation(Example Only)

• Contract Type: Blue Choice • QBRP: 4% (example only) • Outpatient Discount: 15% (example only) • Services: This claim is for an emergency room visit,

observation, drugs and medical supplies. The MAP for observation is one day’s average semi-private room rate regardless of the length of time the patient is in observation.




0250 NA 80.22 NO 80.22

Apply BC Discount (15%) X .85

Allowance with BC Discount Applied: 68.19

No QBRP because code is not MAP'd

0450 99284 105.00 NO Charge: 105.00

Apply BC Discount (15%) X .85

Allowance with BC Discount Applied: 89.25

No QBRP because code is not MAP'd

0762 99218 800.00 YES Apply ASVP Room Rate, BC Discount and QBRP

MAP: 675.00

Apply and add QBRP Incentive of 4%

+ 27.00

New MAP 702.00

Apply BD Discount of 15% X .85

New MAP with QBRP and BD Discount Applied: 596.70

TOTALS 985.22 754.14

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