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A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS
First Quarter 2012

BCBSMT Implements Convenient Provider Self-Service

Recently the Blue Cross and Blue Shield of Montana (BCBSMT) Healthcare Services Department staff collected data concerning the volume and content of the calls they were receiving from providers, and they determined that our online resources can answer many of your questions about the following issues: 

Provider File Maintenance

Rather than your office having to call to update its address or tax ID number, send us your changes directly through our website to our provider database maintenance staff.  On our website from the Provider Home page, click on the blue button titled “Update My INFORMATION”.  Complete the online form with your updates and then click submit.  Your request will be sent directly to staff to complete the update. 

Contract Requests

If your office will have a new participating provider soon and contracts are needed, send your contract request to the Provider Relations Department at BCBSMT.  On our website from the Provider Home page, click on the blue button titled “I Want to Be a PARTICIPATING PROVIDER.”  Complete the online form with your information and then click submit.  Your request will be sent directly to the HCS Specialists to send the contracts to the provider.

Electronic Funds Transfer

When a request for Electronic Funds Transfer is needed, refer to the Health-e-Web FAQ section titled BCBSMT Electronic Funds Transfer (EFT).  Health-e-Web manages the collection and processing of the necessary paperwork.  Providers need to have three things in place before an EFT can begin:

  1. Providers must submit electronic claims (837s).
  2. Providers must receive QNXT electronic remittance advice (835s).
  3. Providers must be prepared for paper Provider Claims Registers (PCRs) to be discontinued.  PCRs are available online once logged, from the left navigation of reports.  

Fee Schedules

If your office is seeking reimbursement allowances or a copy of the fee schedule, register for Provider Online Services.  Once registered, access to compensation policies, payment history, claim status, PRC's and a wealth of other information is available too.  

We hope these online services save you time, paper, and effort.

BCBSMT Goes Green with Paperless Records Request Process

The BCBSMT Integrated Healthcare Management Clinical Operations Department has gone green by recently deploying a paperless records request process.  That will, of course, translate into cost savings for both provider offices and BCBSMT through a decreased need for paper, envelopes, and postage.
 
But this new process can translate as well into another great benefit for providers and their patients!

As you may have noticed, we are now faxing our Requests for Additional Information to you.  We recognize that our requests for records have aggressive turnaround times and that providers are often unable to respond in time simply because of the days lost in regular mail.  Your receiving, and returning, these requests by fax will save time, and you’ll no longer be stuck with frustrating snail mail delays.

An additional benefit to our paperless request process is that your patients may get claim information back quicker because claims are automatically processed if we have received all the necessary information within a 10-day window.  For claims received outside the 10-day window, our system must initially stop them for adjustments and deny them — and nearly 50% of mail comes in after claims have been denied, requiring a considerable amount of manual work and causing a delayed response to your patients. 

To help the new process run smoothly, your help is requested! 

  1. We do not have a complete list of fax numbers for Provider Medical Records offices.  Please email us at IHM_Records_Requests@bcbsmt.com with your Medical Records Department fax numbers. 
  2. Please respond to our records requests by fax at 406.441.3064. 

We thank you for all you do to provide the best care possible for your patients and our members!

Electronic Funds Transfer for Providers Also Goes Paperless

Are you interested in helping BCBSMT GO GREEN and in improving the efficiency of your operations? Read on to learn more about BCBSMT’s Electronic Funds Transfer (EFT). 

To be eligible to receive EFT, you must:

  • Submit  electronic claims (837s)
  • Receive QNXT electronic remittance advice (835s)
  • Be ready to have paper Provider Claims Registers (PCRs) discontinued.  PCRs are still available on line. 

To streamline this process and ensure compliance with the electronic requirements, Health-e-Web (HeW) will manage the collection of paperwork for claims (837s), ERA (835s), and EFT.  They in turn will coordinate with BCBSMT to ensure a smooth transition to going paperless. 

If you are interested in applying for EFT, on the Provider home page under Announcements select New Electronic Funds Transfer (EFT), learn more.  That link, which is to HeW, will guide you through the EFT application process and provides a downloadable application form.  Once you have completed that form, you may:

  • Scan and email it to enrollment@hewedi.com
  • Fax it to HeW at 406-449-0190
  • Call HeW at 8775655457, Option 1
  • Mail it to:

HeW
Attention: Enrollment at HeW
P.O. Box 1540
Helena, MT 59624

Please note that EFT is not available from claims processed in LRSP, BCBSMT’s legacy processing system.  LRSP Provider Claim Registers and checks will continue to be sent as they are today.

New Molecular Pathology Codes Developed

The American Medical Association (AMA) has developed 101 new molecular pathology codes (CPT 81200-81408) for an effective date of January 1, 2012.  These codes are stand-alone and should not be used with the existing “stacking” codes (83890-83914 and 88384-88386).  However, the Centers for Medicaid and Medicare Services (CMS) recently issued billing direction to providers in CR 7654, requesting that they bill the existing “stacking” codes that are required for payment and the new single CPT test code (referred to above as and hereinafter called “new molecular pathology codes”), reflecting a charge for each code billed.  The new molecular pathology code will be bundled into the existing “stacking” codes, and payment for them is subsumed by the payment for the existing “stacking” codes.

BCBSMT requires providers to submit the existing “stacking” codes, which are used for compensation purposes.  Providers are also required to submit the new molecular pathology code if it describes the test that is being performed and billed with the existing “stacking” codes.  BCBSMT requests that when providers bill the new molecular pathology codes they use the following guidelines:

  • Submit both the new Molecular Pathology code (81200-81408) along with the existing “stacking” code(s) (83890-83914 and 88384-88386) and reflect a charge on both the new code and the existing “stacking” codes.
  • The new Molecular Pathology code will be denied as inclusive of the existing “stacking” codes.
  • Do not bill the new Molecular Pathology code alone, without the corresponding existing “stacking” codes.  The “stacking codes” are required in order to determine compensation.  If the codes are not submitted on the claim, BCBSMT will request this information from the provider for any claims received between 01/01/2012 and 03/31/2012. After this date, if the existing “stacking” codes are not billed with the new Molecular Pathology code, the claim will be denied for insufficient information.
  • Effective claim receipt date of 4/1/12, if the provider has submitted only the New Molecular Pathology code and claim is denied as “The information received is not adequate to continue processing the claim.  We will resume processing when additional information is received from the provider.” a corrected claim will be required that includes the “stacking codes” in conjunction with the New Molecular Pathology Codes.
  • If a Molecular Pathology code has been denied for medical necessity, follow standard procedures for review.
  • If the Molecular Pathology code has been denied ERISA when records not received, follow standard procedures for records receipt.

 

Preventable Adverse Events Policy Updated

In accordance with the Blue Cross and Blue Shield Association Inter-Plan Policy, which was developed using CMS standards as a guideline, BCBSMT adopted standards regarding PAEs and the billing of the Present on Admission (POA) Indicator.  PAEs are defined as “adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.”  They include both Hospital-Acquired Conditions (HAC) and Never Events.  BCBSMT has defined 15 occurrences as PAEs.

Federal regulations recently added five new ICD-9-CM codes specific to HAC categories.  BCBSMT has added these new codes to the Preventable Adverse Events/Present on Admission Policy to remain consistent with CMS.  The new ICD-9-CM codes are listed below.

ICD-9-CM Code Description 
Falls and Trauma 
808.44 Multiple closed pelvic fractures without disruption of pelvic circle
808.54 Multiple open pelvic fractures without disruption of pelvic circle
Surgical Site Infection Following Bariatric Surgery for Obesity
539.01 Infection due to gastric band procedure
539.81 Infection due to other bariatric procedure
Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures
415.13 Saddle embolus of pulmonary artery

Provider Manual Update: Chapter 10  -- Coordination of Benefits

Most group health benefit plans contain a Coordination of Benefits (COB) provision.  When members and dependents are covered under two or more group and/or individual plans, benefits for these plans will be coordinated, so compensation does not exceed the BCBSMT allowable fee. BCBSMT does not coordinate benefits for certain policies including, but not limited to, the following:

  • AARP policies
  • Cancer supplement policies
  • Intensive care policies
  • Long-term care policies
  • Hospital indemnity policies
  • AFLAC policies
  • Dental or vision benefits

Circumstances when COB information is needed include, but are not limited to, the following:

  • Coverage by two or more medical BCBSMT plans
  • Medical coverage under another carrier (commercial) and medical coverage by one or more BCBSMT plans
  • Medicare and/or coverage by one or more BCBSMT plans

BCBSMT Seeking Pharmacy and Therapeutics Committee Members

BCBSMT is seeking physicians interested in serving on the Pharmacy and Therapeutics Committee.  The Pharmacy and Therapeutics Committee is charged with review of newly released pharmaceutical entities, evaluating them for efficacy, safety, and uniqueness within their specific class.  In addition, the committee is responsible for formulary placement of new and existing products.
 
Interested providers will be selected to the committee based on need and specialty.  A roster of interested individuals will be maintained for future reference.

The committee meets quarterly, generally the 3rd Wednesday of February, May, August, and November.  Meetings are generally less than 90 minutes and occur in the evening beginning at 6 p.m.  Attendance can either be in person or by teleconference.  An honorarium is paid for participation.

If you are interested, please email Mark Meredith, PharmD, at Mark_Meredith@bcbsmt.com by April 15, 2012.

Finding Online Claim Status is Simple and Easy

When you log into our website as a provider, you can immediately retrieve the status of your claim using a variety of tools.

  1. Claim Search – this option is located on the main screen that appears once you log into the site.  You can view any claim that has been submitted by your office to BCBSMT for Montana members that have an alpha prefix beginning with “YD” or an FEP member that has a Subscriber ID beginning with “R.” 
  2. Blue Card Host Claim Search – this new option is located directly below the current Claim Search area.  You must enter the date you submitted the claim to BCBSMT.  Your search criteria will help us locate the claim on either of our processing systems.  As of January 21, 2012, we are switching processing systems for Blue Card Host Claims.  We are staggering the number of claims we move to the new system by selecting a few Plans at a time.  The member’s alpha prefix and the date the claim was submitted will determine which system we will use to locate your specific claim.   The first set of alpha prefixes being switched to the new system are MMY, WMW, LCB, and PNK. 
  3. Blue Exchange/FEP – another helpful option is to submit a request through Blue Exchange/FEP.  This option is located on the left hand menu found under the heading of Providers.  This will allow you to submit claim-specific information that we will send to the appropriate Plan for a current status of your claim.  Most often the claims status returns within a minute, but the response time is dependent on the Home Plan’s current online status.

 

BCBSMT Access and Availability Standards

Participating providers treat BCBSMT members as they would any other patient and have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times.  Participating providers must meet the following appointment standards:

1. Emergency services must be made available and accessible at all times.
2. Urgent care appointments must be available within 24 hours.
3. Appointments for non-urgent care with symptoms must be made available within 10 calendar days.
4. Appointments for immunizations must be available within 21 calendar days.
5. Appointments for routine or preventive care must be available within 45 calendar days.

Emergency Services and Emergency Medical Condition

Participating providers are required to have 24-hour availability of emergency services and qualified on-call coverage available to BCBSMT members. 

Emergency Services means health care items and services furnished or required to evaluate and treat an emergency medical condition.

Emergency Medical Condition is a condition manifesting itself with symptoms of sufficient severity, including severe pain, in which the absence of immediate medical attention could reasonably be expected to result in any of the following:

1. The covered person’s health would be in serious jeopardy.
2. The covered person’s bodily functions would be seriously impaired.
3. A body organ or part would be seriously damaged.

Urgent Care

Participating providers must see BCBSMT members within 24 hours of their request for an appointment.

Urgent Care is health care that is not an emergency service but is necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.

Non-Urgent Care with Symptoms

Participating providers must see BCBSMT members within 10 calendar days of their request for an appointment.

Non-Urgent Care is health care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature.

Routine Care

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment.

Routine Care is health care for a condition that is not likely to substantially worsen in the absence of immediate medical intervention and is not an urgent condition or an emergency.  Routine care can be provided through regularly scheduled appointments without risk of permanent damage to the person’s health status.

Preventive Care and Immunizations

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment for preventive care and within 21 calendar days of their request for an appointment for immunizations.

Preventive care and Immunizations are health care services designed for the prevention and early detection of illness in asymptomatic people.

More information is available in the BCBSMT Provider Manual .  If you have suggestions for improvement or content, email your Provider Account Consultant at HCS-X6100@bcbsmt.com or call 1.800.447.7828, Extension 6100 Option 3. 

TriWest Medical Reports

Please note that if you receive medical reports for a TRICARE beneficiary, you must fax them to TriWest within 10 working days to 1.866.867.7926.

According to page 88 of the provider handbook: "To help ensure continuity of care, all TRICARE network specialty providers are responsible for communicating the results of an examination and/or treatment to the referring civilian or military provider, who is usually the beneficiary's PCM, within 10 working days."

We thank you for promptly attending to this matter, which will help serve all of your TRICARE patients efficiently.

Secure Provider Website Users Can Now Submit Attachments with Claims

Registered users of TriWest Healthcare Alliance’s secure provider website at TriWest.com can include up to three attachments with a new or corrected web submitted claim.  Each attachment can be up to 5 MB in size.  It is no longer necessary to submit a paper claim when asked by TriWest to submit an invoice or other documentation with the claim.

When a registered user is submitting a claim online and gets to the enter claim information section, they can just scroll to the bottom of the page to “Attach Document File(s).” From there, just click on the Browse button and select the document(s) you want to attach.  It’s that easy!

If you’re not registered for the secure provider website at TriWest.com, you can’t take advantage of this and the many other features that registered users enjoy 24/7/365.  Set up an account on TriWest.com to:

  • Verify patient eligibility
  • Research covered benefits and check referral/authorization and medical review requirements for specific codes
  • Submit referrals/authorizations online and check their status regardless of how the request was submitted
  • Submit claims online and check claim status regardless of how the claim was submitted
  • Download remittance advices
  • Download claims status reports
  • Submit corrected claims
  • Submit claims correspondence/Webmail

TriWest Enhances Its Provider Directory

To better serve its customers, TriWest Healthcare Alliance (TriWest) has restyled the online Provider Directory.  Visitors will notice that it now shares the same look as the rest of the website.

The biggest improvement is that instead of navigating through a drop-down menu to begin, users now select from a group of easy-to-read icons.  This more intuitive approach helps ensure that you enjoy a consistent user experience no matter what part of TriWest.com you’re visiting.

TriWest also made one important addition: Calling out the Urgent Care/Extended Hours Directory, which is located in the bottom right of the Provider Directory landing page.  This makes it easier for beneficiaries to find an urgent care center close to them.

Once you’re on the directory, you can search for a provider by:

  • Name
  • Facility
  • Location
  • Group Name
  • Specialty
  • Military Clinic
  • Specific Hawaiian island

The provider directory allows you to search and filter search results on provider areas of interest (AOI).  AOIs are self-reported categories of practice focus that assist users in making targeted decisions in selecting a provider.  AOIs are available for medical/surgical and behavioral health providers, hospitals, skilled nursing facilities, durable medical equipment suppliers, radiology centers, and urgent care centers.

You should check the online TriWest provider directory at TriWest.com/Provider to ensure your information is accurate.  If it needs to be updated or if you wish to submit your AOI so that it will be displayed 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.

You can access the Provider Directory under the Find a Provider tab at www.TriWest.com.

 
 
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