A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS
Second Quarter 2012
New Consumer Tools To Be Launched Soon
Blue Cross and Blue Shield of Montana (BCBSMT) is committed to ongoing collaboration with health care providers in delivering information and tools to help patients make informed decisions when seeking care. As part of that effort, BCBSMT is announcing the deployment of a suite of Blue consumer engagement initiatives that will launch in July 2012 on the redesigned Blue National Doctor & Hospital Finder website, which is the provider directory for all the Blue system. Deployment of these new tools is an initiative across the Blues system-wide.
Effective in July 2012, the provider directory/search functionality for BCBSMT members will become the Blue National Doctor & Hospital Finder. The new Provider Finder may be accessed directly from www.bcbsmt.com, just as the current provider finder is accessed today. Enhanced search capabilities are being added, and additional provider information is being added, to provide seamless access to cost, quality, patient review of physicians and provider demographic information that is customized, comprehensive, and more helpful to our members.
The following tools will be made available in July 2012: Approximately 85-90% of patient reviews are positive.
Patient Review of Physicians (PRP) allows Blue members to view and post reviews of doctors and other professional providers based on their patient experiences. Approximately 85–90 percent of patient reviews are positive, and BCBSMT has implemented a rigorous process that authenticates reviews prior to posting on the Blue National Doctor & Hospital Finder website. Not only do patient reviews help members make more informed decisions when choosing a doctor, they are also a valuable way for physicians to gain insights into their current patients’ experiences and attract new patients.
Physician Quality Measurement (PQM
This on-line survey tool will allow members to review their provider visits based on:
The survey will also feature a comments section, allowing customers to explain their ratings. These categories are designed to solely reflect member experience with a physician, not to reflect the quality of care they received.
The patient satisfaction survey results will be available for all members to view under the "Patient Satisfaction" tab. A three-star scale will show how members rate a provider and member comments will be available to view.
) is based on select HEDIS® physician performance measures that are displayed to assist patients in choosing a doctor. The PQM program will display these nationally endorsed and evidence-based physician quality performance measures along with supporting data, local comparison norms and educational consumer information. The Blues® believe that care improvement comes from a combination of measuring what can be measured, promoting ongoing practice improvement and recognizing the champions of care delivery. PQM is the Blue program that supports making measured performance information available to consumers.
Results for specific HEDIS® physician performance measures will be displayed for Primary Care Physicians (PCPs) for whom BCBSMT has a valid member sample available. The performance data will be aggregated for all physicians in the physicians practice group for each measure. PCPs will be sent their performance measure data in the near future, under separate cover and prior to being submitted for display on the Blue National Doctor & Hospital Finder website.
Blue Physician Recognition (BPR)
supports the Blue care improvement philosophy by promoting and recognizing physicians and their health care partners that have demonstrated a commitment to delivering quality and patient-centered care as determined by BCBSMT. The names of physicians and their health care partners who participate in the BCBSMT Patient Centered Medical Home (PCMH) will be displayed on the Blue National Doctor & Hospital Finder with the BPR icon. The BPR program recognizes quality improvement efforts through the BCBSMT PCMH Program and highlights physicians and their partners as champions of quality care in their communities.
These new tools will simplify how our members access information and will provide related decision support tools, allowing them better navigation of the health care system.
Members Must Provide Claims Accident Information
When medical claims are potentially related to an accident, the Blue Cross and Blue Shield of Montana (BCBSMT) member must be the one to provide the necessary information.
Since the processing of claims can be directly affected by the answer to a Letter of Inquiry (LOI), BCBSMT can only accept accident information from the member (patient, parent, policyholder, etc.). Accident information can never be taken from a provider without either verifying it with the Member or accompanying it by a signed statement from the Member.
We thank all of our provider offices for abiding by this procedure.
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
The process changes described above will not apply to members covered under self-funded group policies.
In addition, benefits will continue to be coordinated for medical dental services. Any secondary dental claims for which benefits have been coordinated prior to May 1, 2012, will not be adjusted.
With this change in claim processing, combined payments may result in overpayments. These overpayments should be refunded directly to the patient. Self-funded groups will continue to coordinate secondary dental services
Where Do Ancillary Providers File Blue Claims?
Generally, as a health care provider you should file claims for your Blue Cross and Blue Shield patients with the local Blue Plan. However, if you are an ancillary provider, you will need to be aware of the criteria used to determine who the local Blue Plan is before filing your claim.
Ancillary providers are Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies, and Specialty Pharmacy providers. The local Blue Plan as defined for ancillary services is as follows:
Independent Clinical Laboratory (Lab)
- The Plan in whose state* the specimen was drawn.
Durable/Home Medical Equipment and Supplies (DME)
- The Plan in whose state* the equipment was shipped to or purchased at a retail store.
- The Plan in whose state* the Ordering Physician is located.
*If you contract with more than one Plan in a state for the same product type (e.g., PPO or Traditional), you may file the claim with either Plan.
How to file
| Where to file
| Independent Clinical Laboratory (any type of non hospital based laboratory)
Types of Service include, but are not limited to:Blood, urine, samples, analysis, etc.
Field 17B on CMS 1500 Health Insurance Claim Form or
Loop 2310A (claim level) on the 837 Professional Electronic
|File the claim to the Plan in whose state the specimen was drawn*
* Where the specimen was drawn will be determined by which state the referring provider is located.
| Blood is drawn* in lab or office setting located in Montana. Blood analysis is done in Washington. File to: BCBS of Montana
*Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn.
|Durable/Home Medical Equipment and Supplies (D/HME)
Types of Service include, but are not limited to: Hospital beds, oxygen tanks, crutches, etc.
| Patient’s Address:
Field 5 on CMS 1500 Health Insurance Claim Form or
Loop 2010CA on the 837 Professional Electronic Submission.
Field 17B on CMS 1500 Health Insurance Claim Form or
Loop 2420E (line level) on the 837 Professional Electronic Submission.
Place of Service:
Field 24B on the CMS 1500 Health Insurance Claim Form or
Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions.
Service Facility Location Information:
Field 32 on CMS 1500 Health Insurance Form or
Loop 2310C (claim level) on the 837 Professional Electronic Submission.
File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store.
A. Wheelchair is purchased at a retail store in North Dakota.
File to: BCBS of North Dakota
B. Wheelchair is purchased on the internet from an online retail supplier in Florida and shipped to Montana.
File to: BCBS of Montana
C. Wheelchair is purchased at a retail store in Montana and shipped to Wyoming.
File to: BCBS of Wyoming.
How to file (required fields)
Where to file
Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary. Include, but are not limited to: injectable, infusion therapies, etc.
Field 17B on CMS 1500 Health Insurance Claim Form or
Loop 2310A (claim level) on the 837 Professional Electronic Submission.
File the claim to the Plan whose state the Ordering Physician is located.
Patient is seen by a physician in Montana who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Arizona, where the member lives for 6 months of the year. File to: BCBS of Montana
- The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue Plan where the claim is filed.
- Providers are encouraged to verify Member Eligibility and Benefits by contacting the phone number on the back of the Member ID card or calling 1-800-676-BLUE, prior to providing any ancillary service.
- Providers that use outside vendors to provide services (example: Sending blood specimen for special analysis that cannot be done by the Lab where the specimen was drawn) should use in-network participating Ancillary Providers to reduce the possibly of additional member liability for covered benefits. In-network participating providers may be identified on the provider finder at www.bcbsmt.com.
- Members are financially liable for ancillary services not covered under their benefit plan. It is the provider’s responsibility to request payment directly from the member for noncovered services.
Please be aware that in the event a Plan incorrectly receives an ancillary claim directly from a provider, the Plan will return the claim to the provider with instructions to file the claim with the approprie Plan.
Corrected claims are sent to the (BCBSMT) Customer Service Department to adjust the original claim. Sending them to the Claims Department will result in denial of the claim as a duplicate claim or cause an overpayment. Do not send a corrected claim electronically because it will also be denied as a duplicate or potentially overpay. Clearly indicate on the claim Corrected Claim, Corrected Diagnosis, or some other indicator identifying the claim as corrected, and what is being corrected (e.g., procedure code, date of birth, etc.).
Send all corrected claims, except Federal Employee Program and BlueCard Host, to:
Cross and Blue Shield of Montana
P.O. Box 4309
Helena, MT 59604
Submit corrected Federal Employee Program and BlueCard Host claims to:
Blue Cross and Blue Shield of Montana
P.O. Box 7982
Helena, MT 59604
A corrected claim or claim review request form can be found on the BCBSMT website, www.bcbsmt.com, under provider forms. Use this form to correct a previously submitted claim or to ask for a review of a denied claim.
Records must be included to document why the claim should be corrected for the change to be made.
Streamline Your Work – Attend aTRICARE Provider Seminar
For the latest information on TRICARE® referrals and authorizations, claims and reimbursement, and TriWest’s secure provider website, plan to attend a 2012 TRICARE provider seminar. Presented by TriWest Healthcare Alliance (TriWest), these seminars will be held from April 1 through September 30 throughout the TRICARE West Region. Go to TriWest.com/Provider>Stay Updated>TRICARE Provider Seminar Registration to register.
Who Should Attend?
Providers, practice managers and office staff responsible for eligibility verification, referrals and authorizations, and claims and collections, as well as practice managers, should attend.
This seminar was not developed for providers or staff new to TRICARE. If you are not already experienced with TRICARE, you should take a TRICARE 101 or Behavioral Health TRICARE 101 webinar or eSeminar before attending a live seminar. Go to TriWest.com/Provider>Stay Updated to register for a webinar or take an eSeminar.
What to Expect:
This year’s seminars are for experienced TRICARE staff and will focus primarily on referrals/authorizations, claims/reimbursement, and secure website functionality.
When you attend a seminar, you will receive:
- The newest Provider Handbook and Quick Reference Guides
- Updates on the latest enhanced functionality of the secure provider website
The length of the seminars is approximately 2.5 hours. End times may vary based on audience participation.
There is no charge to attend a seminar.
What Should I Do Prior to Attending a Seminar?
If you are not already registered for the secure provider website, register before attending the seminar so you can obtain the full benefit while attending the live seminar.
If you are not already experienced with TRICARE administrative requirements, please take a TRICARE 101 or Behavioral Health TRICARE 101webinar or eSeminar before attending the live seminar.
If you wish to have a copy of the seminar slides for note-taking or reference purposes, please print the slides and bring them with you to the seminar. Several days prior to the seminar, you will receive an email with a link to the seminar slides.
Benefits of Online Seminar Registration
Registering online is the most convenient way to preregister for a seminar and includes these benefits:
- Immediate email confirmation of your registration
- Reminder email notices prior to your scheduled seminar
- Eligibility to participate in a drawing for a small prize at the seminar
Please note that confirmations are emailed to you only when your email address has been provided to us with your registration. Please add email@example.com to your safe sender list to ensure that you receive your confirmation from TriWest. Note: we will not sell or distribute your email address to other companies, with the exception of your Local TRICARE Representative.
Please email firstname.lastname@example.org if you have questions about:
- How to register for a seminar
- How to change your registration to attend a different seminar, cancel your registration, or add additional people to your registration
- How to register if six or more people from your practice or facility wish to attend