THIS MANUAL CONTAINS A REQUIRED DISCLOSURE CONCERNING BLUE CROSS AND BLUE SHIELD OF TEXAS CLAIMS PROCESSING PROCEDURES
Blue Choice PPOSM Physician, Professional Provider, Facility and Ancillary Provider - Provider Manual Table of Contents (TOC) Section Welcome to the Blue Choice PPO Network Support Services
Physician, Professional Provider, Facility and Ancillary Providers Roles & Responsibilities
Topic
Page
Blue Choice PPO Network Objective Blue Choice PPO Network Benefits Information Provided in this Manual Modifications
TOC TOC TOC TOC
13 13 13 14
Blue Choice PPO Overview Blue Choice PPO Geographical Regions Blue Choice PPO Support Areas BCBSTX Commitment Network Management Department Objective Network Management Representatives Network Management Regional Office Locations Medical Directors & Medical Advisory Committees Employer/Employee Training Physician Professional ProviderFacility and Ancillary Provider Orientation/Training Online Provider Directory/Website Information Blue Review Newsletters Secure Server Policy Provider Access & Servicing Strategy (PASS) Educational Opportunities Provision of Contract Copies How to Request a Sample of Maximum Allowable Fees
A A A A A A A A A A
— — — — — — — — — —
2 2 2 2 3 3 3 4 5 5
A A A A
— — — —
5 5 5 6
Sample Fee Schedule Request Online Form
A—8
Provider Customer Service Provider Customer Service Telephone Numbers & Hours
A—9 A—9
Blue Choice PPO ID Card Using the ID Card Other Information Department of Insurance (DOI) Requirements Blue Choice PPO Subscriber Access Blue Choice PPO ID Card Information Blue Choice PPO Sample Group ID Card Exclusive Provider Organization (EPO) Plan BlueEdge Products
B B B B B B B B B
A—6 A—7
— — — — — — — — —
4 4 5 5 6 6 7 8 8
Continued on next page A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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Table of Contents, continued Section Physician, Professional Provider, Facility and Ancillary Providers Roles and Responsibilities
Topic
Page
Subscriber Eligibility Questions Eligibility Statement Premium Payment for Individual Plan Verification Verification Procedure Delegated Entity Responsible for Claim Payment Required Elements to Initiate a Verification Declination Additional Fees Charged By Physicians, Professional Providers, Facility and Ancillary Providers Beyond Copayment and Coinsurance Role of the Primary Care Physician (PCP) Role of PCP for Blue Choice PPO Subscribers Referrals to Specialty Care Physicians, Professional Providers, Facility or Ancillary Providers Role of the Specialty Care Physicians, Professional Providers, Facility or Ancillary Providers Role of the OBGyn Notification of Obstetrical & Newborn Care Predetermination Requests Physician, Professional Provider, Facility or Ancillary Provider Complaint Procedure Failure to Establish Physician, Professional Provider, Facility or Ancillary Provider Patient Relationship – Performance Standard Failure to Establish Physician, Professional Provider, Facility or Ancillary Provider Patient Relationship – Procedures Failure to Establish Physician, Professional Provider, Facility or Ancillary Provider Patient Relationship – Sample Letter from Physician, Professional Provide, Facility of Ancillary Provider to Subscriber
B B B B B B B B B
Allergy Services - Important Notice Laboratory Services Radiology Services Overview Provider Transparency & AIM’s OptiNet Assessment Tool Advanced Diagnostic Imaging Low-Tech Imaging Physician’s Guide for Radiology Services BlueCard Program How to Join BCBSTX Provider Networks To Request a BCBSTX Provider Record ID
B B B B
— — — — — — — — —
10 10 10 11 11 11 12 13 14
B — 15 B — 18 B — 19 B — 20
B — 22 B — 23 B — 24 B — 25 B — 26
B — 27 B — 29
— — — —
30 32 33 34
B — 34 B B B B B
— — — — —
36 37 40 43 45
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Table of Contents, continued Section Physician, Professional Provider, Facility and Ancillary Provider Roles and Responsibilities, cont’d
Topic
Page
Change in Your Status or Changes Affecting Your Provider Record ID Request Contract/Agreement/Network Participation Credentialing Process for Office Based Physicians, Professional Providers, Facility and Ancillary Providers Getting Started With CAQH Credentialing Process Hospital or Facility Based Providers Sample Facility Based Provider Application Facility Based Provider Type Contact List Credentialing Updates Recredentialing Credentialing Frequently Asked Questions Medical Advisory Committee Credentialing Review Requests Physician and Professional Provider Termination Process Urgent Care Center (UCC) Criteria Urgent Care Center Services Billed Using CPT Code S9088 Affordable Care Act Risk Adjustment
iExchange System for Referrals, Maternity Notifications, Select Outpatient Preauthorizations and Inpatient Admissions
Preauthorization/Notification/Referral List iExchange System for Referrals, Maternity Notifications, Select Outpatient Preauthorizations and Inpatient Admissions Expedited Appeal Process Standard Appeal Process Provider Request for Case Match Review
B — 48 B — 49 B — 53 B — 60 B B B B B B B B
— — — — — — — —
62 63 64 65 67 72 73 74
B — 76 B — 76 B — 76 B — 77 C—2 C—2 C—3 C—3 C—3
To Appeal an Adverse Determination for Medical Necessity or Experimental/Investigational Appeal Process for Denials of Out-of-Network Requests and Non-covered Benefits
B — 47
C—3 C—4
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Table of Contents, continued Section Referral Notification Program
Preauthorization
Topic
Page
Referral Notification Program Introduction When is a Referral Necessary? Important Information About the Referral Notification Program Information Necessary for Referral Notification Notification Procedure Through iExchange Non-iExchange Referral Notification Procedure Referrals Out-of-Network/Plan Procedure Out-of-Network Referral to an Out-of Network Provider When an In-Network Provider is Available
D—2 D—2 D—4 D—4 D—4 D—5 D—5
Preauthorization Overview What Requires Preauthorization eviCore Preauthorization Program Responsibility for Preauthorization When to Preauthorize Does 23 Hour Observation Require Preauthorization
E—3 E—3 E—3 E—3
Preauthorization Web Access, Telephone Numbers & Hours After Hours Calls Faxing Preauthorization Requests Information Necessary to Preauthorize Information About the Preauthorization Program Accessibility of Utilization Management Criteria Extended Care Preauthorizations – Home Health Services Extended Care Preauthorizations – Hospice Extended Care Preauthorizations – Home Infusion Therapy Extended Care Preauthorizations – Skilled Nursing Facility Extended Care Preauthorization – Important Note Preauthorization of Inpatient Care
E—4
Non-Emergency Elective Medical/Surgery Admission Guidelines Urgent/Emergent Admissions Procedure Admission on Day of Surgery Concurrent Review Concurrent Review of Inpatient Admissions Responsibility of Concurrent Review Information Needed When Requesting an Extension Extension Review Procedure Discharge Planning Case Management Services Case Management Examples Physician/Professional Provider Involvement Referrals to Case Management Updated 11-16-17
D—3
E—3 E—3
E—4 E—4 E—4 E—5 E—6 E—7 E—7 E—7 E—7 E—7 E—8 E—9 E—9 E—9 E—9 E—9 E — 10 E — 10 E — 10 E — 10 E — 11 E — 11 E — 12 E — 12 E — 12 E — 13
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Table of Contents, continued Section Preauthorization, cont’d
Filing Claims
Topic
Page
Evaluation of New Technology Emergency Care Services Emergency Inpatient Admissions Rendered Outside the Blue Choice PPO Service Area Emergency Hospital Admission Continuity of Care Program Criteria Continuity of Care Program Procedure
E — 13 E — 14 E — 14
Claims Processing Questions Non Covered Services Changes Affecting Your Provider Record ID NPI Number Change, Name Change, Change in Your Address, etc. Ordering Claim Forms Claim Filing Deadlines
F—7 F—7 F—7
E — 14 E — 15 E — 16
Address For Claims Filing & Customer Service iExchange Confirmation Number Paperless Claims Processing:An Overview Availity , L.L.C. -Patient, Not Paperwork Overview Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT) Electronic Payment Summary (EPS) Electronic Claim Submission & Payor Response Reports Payor Response Report System Implications What are the Benefits of EMC/EDI? Payer Identification Code What BCBSTX Claims Can Be Filed Electronically? How Does Electronic Claims Filing Work? Submit Secondary Claims Electronically Duplicate Claims Filing is Costly Claims Submission – Timely Claims Filing Claims Filing Reminders Prompt Pay Prompt Pay Legislation - Penalty Prompt Pay Legislation- Definition of a Claim Prompt Pay Legislation – Statutory Claim Payment Periods Prompt Pay Legislation– Statutory Penalty Amount Coordination of Benefits and Patient's Share Coordination of Benefits (COB) Subrogation Coordination of Benefits (COB) Questionnaire Prompt Pay Penalty Legislation-Coordination of Benefits Correct Coding
F—8 F—8 F—8 F—9 F—9 F—9 F — 10 F — 10 F — 10 F — 10 F — 11 F — 11 F — 12 F — 12 F — 13 F — 13 F — 13 F — 13 F — 14 F — 14 F — 15 F — 15 F — 16 F — 17 F — 17 F — 18 F — 19 F — 19 F — 20 F — 21
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Table of Contents, continued Section Filing Claims, cont’d
Topic
Page
Spitting Charges on Claims Services Rendered Directly by Physician Professional Provider Facility or Ancillary Provider Billing for Non Covered Services Surgical Procedures Performed in the Physician’s, Professional Provider’s, Facility or Ancillary Provider’s Office Contracted Physicians, Professional Providers, Facility or Ancillary Providers Must File Claims CPT Modifier 50 Bilateral Procedures – Professional Claims Only Untimed Billing Procedure CPT Codes Proper Speech Therapy Billing Submission of CPT 99000 With Modifier 59 Care Coordination Services Urgent Care Center Services Billed Using CPT Code S9088 National Drug Code (NDC) Billing Guidelines for Professional Claims Billing and Documentation Information and Requirements
F — 21 F — 21 F — 22 F — 22 F — 24 F — 23 F — 24 F — 24 F — 25 F — 25 F — 25 F — 26 F — 27 F — 28
Permissible Billing Pass through Billing Under Arrangement Billing All Inclusive Billing
F — 29
Other Requirements and Monitoring
CLIA Certification Requirement Review of Codes Limitations and Conditions Obligation to Notify BCBSTX of Certain Changes Assignment Fraudulent Billing
Providers with Multiple Specialties CMS 1500 Claim Form Ordering Paper Claim Forms Return of Paper Claims with Missing NPI Number Sample CMS-1500 (02/12) Claim Form CMS-1500 Key CMS-1500 Place of Service Codes Instructions and Examples of Supplemental Information in Item Number 24 and Reminders Diabetic Education Durable Medical Equipment (DME) DME Benefits Custom DME Repair of DME Replacement Parts DME Rental Or Purchase DME Preauthorization Prescription or Certificate of Medical Necessity Life-Sustaining DME Life-Sustaining DME List Home Infusion Therapy (HIT)
F — 30 F — 31 F — 31 F — 31 F — 32 F — 33 F — 34 F — 35 F — 36 F — 36 F — 36 F — 36 F — 37 F — 37 F — 37 F — 38 F — 39 F — 40 F — 42
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Table of Contents, continued Section Filing Claims, cont’d
Topic
Page
Services Incidental to Home Infusion and Injection Therapy Per Diem
Home Infusion Therapy Schedule Imaging Centers High Tech Procedures Imaging Center Tests Not Typically Covered
F — 43 F — 44 F — 58 F — 58 F — 60
Independent Laboratory Policy
F — 62 F — 62 F — 63
Independent Laboratory - Non Covered Tests
F — 64
Prosthetics/Orthotics Prosthetics & Orthotics – HCPCS Code Description – Non Covered Radiation Therapy Center Claims Filing How to Complete the UB-04 Claim Form What Forms are Accepted Sample UB-04 Form Procedure for Completing UB-04 Form Hospital Claims Filing Instructions – Outpatient Revenue and CPT/HCPCS Codes Outpatient Admission Type Hierarchy Hospital Claims Filing Instructions – Inpatient Type of Bill (TOB) NPI Patient Status Occurrence Code/Date Late Charges/Corrected Claims DRG Facilities Preadmission Testing PreOp Tests Mother & Baby Claims Clinic Charges Provider Based Billing And Clam Examples Treatment Room Claim and Claim Examples Trauma DRG Carve Outs Prior to Grouper 25 DRG Carve Outs for Grouper 25, 26 and 27
F — 65 F — 65
Independent Laboratory Claims Filing Independent Laboratory Preferred Provider
DRG Carve Outs for Grouper 28 DRG Carve Outs for Grouper 29 DRG Carve Outs for Grouper 30 Cardiac Cath/PTCA PTCA/Cardiac Cath Ambulatory Surgery Centers/Outpatient Claims Filing Free Standing Cardiac Cath Lab Centers
F — 71 F — 72 F — 72 F — 73 F — 74 F — 79 F — 80 F — 80 F — 81 F — 81 F — 81 F — 81 F — 81 F — 81 F — 82 F — 82 F — 82 F — 82 F — 83 F — 83 F — 87 F — 89 F — 90 F — 91 F — 91 F — 92 F — 92 F — 93 F — 100 F — 104 F — 105
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Table of Contents, continued Section Filing Claims, cont’d
Topic
Page
Cardiac Cath Lab Procedures Freestanding Cath Lab Center Procedures Electrophysiology Studies Freestanding Cath Lab Centers – Other Procedures Dialysis Claim Filing Free Standing Emergency Centers (FEC) claim Filing Home Health Care Claim Filing Non-Skilled Service Examples for Home Health Care Hospice Claim Filing
Skilled Nursing Facility Claim Filing Rehab Hospital Claim Filing Claim Review Process Proof of Timely Filing Types of Disputes & Timeframe for Request Sample Claim Review Form Recoupment Process Sample PCS Recoupment Professional Provider Claim Summary Field Explanations Refund Policy Refund Letters – Identifying Reason for Refund Provider Refund Form (Sample) Provider Refund Form Instructions Electronic Refund Management (ERM) How to Gain Access to eRM Availity Users Pharmacy
Introduction Pharmacy Network Drug List Evaluation Drug List Updates Generic Drugs Drug Utilization Review (DUR) Overview Covered Pharmacy Services Non-Covered Pharmacy Services Drugs Requiring Preauthorization Specialty Pharmacy Program and Specialty Pharmacy Network Are You a Provider Billing for Compound Drugs? Are You a Provider Billing Unlisted Drugs? Forms
F — 105 F — 109 F — 110 F — 111 F — 111 F — 112 F — 113 F — 114 F — 115 F — 115 F — 116 F — 116 F — 117 F — 118 F — 119 F — 120 F — 121 F — 122 F F F F F
— — — — —
123 124 125 126 126
G—2 G—2 G—2 G—3 G—4 G—4 G—5 G—5 G—6 G—7 G—9 G — 10 G — 11 Continued on next page
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Table of Contents, continued Section Federal Employee Program
Behavioral Health Services
Topic
Page
Federal Employee Program (FEP) Overview No PCP or Referrals Enrollment Codes Option Defined Note: Federal Employee Program Group Number Basic Option ID Card Sample Standard Option ID Card Sample Federal Employee Customer Service Telephone Number and Hours Federal Customer Service Mailing Address Federal Preauthorization Requirement Federal Outpatient Preauthorization How Do I Obtain a Preauthorization? Behavioral Health Preauthorization Federal Claims Filing Instructions Federal Claims Inquiries Federal Pharmacy Programs Federal Disease Management Programs FEP – Blue Health Connection Integrated Behavioral Health Program Behavioral Health Program Components Focused Outpatient Management Program Clinical Screening Criteria Preauthorization Requirements for Behavioral Health Services Responsibility for Preauthorization Preauthorization Process for Behavioral Health Services Failure to Preauthorize Appointment Access Standards HEDIS Indicators Continuity and Coordination of Care Forms Applied Behavioral Analysis (ABA) Initial Treatment Request Forms ABA Treatment Request- Member Schedule Initial Treatment Request Applied Behavioral Analysis (ABA) Managed Care/Concurrent Review Form Clinical Update Request Coordination of Care Electroconvulsive Therapy (ECT) Request
H H H H H H H H
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2 2 2 2 2 3 4 5
H—5 H—6 H—6 H—6 H—6 H—7 H—7 H—7 H—7 H—8 I—2 I—2 I—3 I—4 I—4 I—6 I—6 I I I I I
— — — — —
7 8 8 8 9
Intensive Outpatient Program (IOP) Request Outpatient Treatment Request (OTR) Psychological/Neuropsychological Testing Request Repetitive Transcranial Magnetic Stimulation (rTMS) Transition of Care Request
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Table of Contents, continued Section Behavioral Health Services (cont)
Quality Improvement Program
Topic
Page
Provider Customer Service Phone and FAX Numbers and Behavioral Health Unit Address Provider Customer Addresses for Paper Claims Filing and Phone Numbers Updates Behavioral Health Clinical Appeals Quality Improvement Program Overview Objectives of the Quality Improvement Program Quality Initiatives Support Provided to Quality Improvement Program Medical Director Involvement Quality Improvement Committee Texas Medical Advisory Committee & Texas Peer Review Committee Network Management Representative Involvement On-Site Physician Office Review (POR) Nurses Responsibilities of the Quality Improvement Programs Department
I—9 I — 10 I — 10 I — 10 J J J J
— — — —
3 3 6 7
J—7 J—8 J — 10 J — 11 J — 11 J — 11
Responsibilities of the Hospital Quality Committee
J — 11
Patient Appointment Access Standards Patient Appointment Access Standards Definitions
J — 12 J — 12
Physician Office Review Program Goals of the Office Review Program Safety and Environment Component Laboratory Services Component Radiology Services Component Medical Record-Keeping Practice Component Medical Record Documentation Component Performance Goals Frequency of Office Visit Feedback to Physicians on the Office Review Sample Physician Office Review Worksheet
J — 15 J — 15 J — 15 J — 15 J — 16 J — 16 J— J— J— J—
16 16 17 17
J — 18 J — 20
Principles of Medical Record Documentation Introduction What is Documentation and Why is it Important?
J — 20
How does the Documentation in Your Medical
J — 20
Record Measure Up? Principles of Documentation Sample of Medical Record Review and Medical Record Keeping Documentation Worksheet Frequently Asked Questions About On-Site Office Reviews
J — 21 J — 20 J — 23
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Section Condition Management/ Disease Management Program, Clinical Practice Guidelines and Bridges to Excellence
Privacy of Health Information Blue Compare and Blue Distinction
Page Condition Management/Disease Management Program Overview
K—2
Program Goals – Condition Management/Disease
K—2
Management Programs Condition Management/Disease Management
K—3
Program Overview and Compliance Physician Collaboration
K—4
Gap Closure
K—5
Case Management Program Overview and
K—6
Compliance Outcome Measures
K—6
Special Beginnings® Program
K—7
Clinical Practice Guidelines Overview
K—8
Preventive Care Guidelines
K—8
Clinical Practice Guidelines Bridges to Excellence
K—8 K—9
Privacy of Health Information Overview
L—2
BCBSTX Corporate Privacy Policies
L—3
The BlueCompare Physician Designation Program Measured Specialties and Eligibility BlueCompare Evidence-Based Measures (EBMs) Assessment BlueCompare Designations The Review Process National Guidelines Evidence Based Measures Details on Calculating EBM Scores Definitions BlueCompare Physician Designation Program
M—2
Blue Distinction Program
M—3 M—6 M—7 M—7 M—7 M—8 M—9 M—9
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Table of Contents, continued Section
Topic
Page
Policy Hospital Acquired Conditions Serious Reportable Events
N—2 N—3 N—3
Subscriber Rights and Responsibilities
Subscriber Rights and Responsibilities Communication Rights and Responsibilities
O—2 O—2
Proprietary Information
The material contained in this Provider Manual is proprietary information and is intended for the exclusive use of participating Blue Choice Physicians, Professional Providers, Facility and Ancillary Providers. The information is current as of publication but may be amended from time to time, as provided for in the Blue Choice Provider Agreements.
Hospital Acquired Conditions/ Serious Reportable Events
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Welcome to the Blue Choice PPO Network Blue Choice PPO Network Objective
The Blue Choice PPO network is composed of physicians, professional providers, hospitals, facilities and ancillary providers that have contracted with Blue Cross and Blue Shield of Texas (BCBSTX) with a common objective — to offer cost-effective medical care and services to BCBSTX subscribers through managed care products.
Blue Choice PPO Network Benefits
The Blue Choice PPO network benefits both the BCBSTX subscriber and their physician, professional provider, facility or ancillary provider. The health care benefit products outlined in this Provider Manual feature lower out-of-pocket expenses for the subscriber, providing a strong incentive to seek health care from Blue Choice PPO network physicians, professional providers, facility and ancillary providers.
Information Provided in this Provider Manual
This Provider Manual has been created for Blue Choice PPO network physicians, professional providers, facility and ancillary providers. The information in the Provider Manual is specific to these products: • Blue Choice PPO • BlueEdge • EPO • FEP The subscriber identification (ID) card furnishes information about the products listed above that physicians, professional providers, facility and ancillary providers need to serve their clients effectively. Give special attention to the type of plan and the subscriber ID number. You may also encounter patients with Blue Cross and Blue Shield of Texas products not listed above. You will recognize these products by the identification cards presented by the patients. Guidelines and information for these products may be similar, but are not identical to the information in this Provider Manual. When you see other identification cards, contact Customer Service to receive the most current and accurate information about these products. No matter which Blue Cross and Blue Shield of Texas product your patient may have, each card has a toll-free number to call for information and assistance. Obtaining the correct information will save your staff time and effort. Continued on next page
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Welcome to the Blue Choice PPO Network, continued Information Provided in this Provider Manual, cont’d
This Provider Manual will assist you in the day-to-day administration of the Blue Choice PPO network, providing needed information including: • Characteristics of the health benefit plans/products • Instructions to check eligibility, benefits, claims status and verification • Referral Authorization Select Outpatient Preauthorization, Inpatient Admissions and Maternity Notifications Updates to this Provider Manual will be provided periodically, when changes occur.
Modifications
BCBSTX may amend this Agreement or may modify the Provider Manual where such amendment or modification is materially adverse to physician, professional provider, facility ancillary provider or Medical Group and is not required by the applicable laws only upon ninety (90) days prior written notice to physician, professional provider, facility, ancillary provider or medical group. Physician, professional provider, facility, ancillary provider or medical group may terminate this Agreement by giving written notice of such termination to physician, professional provider or medical group within thirty (30) days of its receipt of such notice of amendment or modification, effective no earlier than the end of such amendment or modification notice period unless within sixtyfive (65) days following the date of such amendment or modification notice BCBSTX gives written notice to physician, professional provider, facility, ancillary provider or medical group that it will not carry into effect such amendment or modification. Physician’s, professional provider’s, facility’s, ancillary provider’s or medical group’s failure to give notice of termination to BCBSTX within thirty (30) days of its receipt of such notice of amendment or modification shall constitute agreement to and acceptance of such amendment or modification by physician, professional provider, facility, ancillary provider or medical group.
Proprietary Information
The information contained in this provider manual is the proprietary information of BCBSTX and is intended for the exclusive use of Blue Choice PPO contracted physicians, professional providers, facility and ancillary providers. The information is current at the time it is being published and may be amended from time to time, as provided in the BCBSTX Provider Agreement.
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