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A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS
Fourth Quarter 2012


And the Survey Says …2011 Provider Satisfaction Survey Results Are In

The results from the Blue Cross and Blue Shield of Montana (BCBSMT) provider satisfaction survey — administered by the Myers Group in Snellville, Georgia — are now in.  Of the 1,800 providers randomly selected from over 5,000 participating providers, 346 responded to the three wave mail survey. We thank each of you who responded.Your feedback is very important to us. The survey measures 20 attributes to assist BCBSMT in developing a comprehensive plan for improving and maintaining your satisfaction with us.

The Top Box scores (excellent and very good response options) for overall health plan satisfaction were 87.3% compared with 86.6% in 2010, which indicates a .70% overall increase in satisfaction with BCBSMT.  In addition, BCBSMT’s ratings were significantly higher than the provider ratings for other health plans in all surveyed attributes.



Summary Rate Scores are the sum of the most favorable response options (Excellent & Very Good)
Mean scores are the average of all respnses
B.o.B represents the 2010 TMG Commercial Book of Business Benchmark whic consists of Primary Care Physicians, Specialists, and Behavioral health Clinicians



Summary Rate Scores are the sum of the most favorable response options (Excellent & Very Good)
Mean scores are the average of all respnses
B.o.B represents the 2010 TMG Commercial Book of Business Benchmark whic consists of Primary Care Physicians, Specialists, and Behavioral health Clinicians





Summary Rate Scores are the sum of the most favorable response options (Excellent & Very Good)
Mean scores are the average of all respnses
B.o.B represents the 2010 TMG Commercial Book of Business Benchmark whic consists of Primary Care Physicians, Specialists, and Behavioral health Clinicians





Summary Rate Scores are the sum of the most favorable response options (Excellent & Very Good)
Mean scores are the average of all respnses
B.o.B represents the 2010 TMG Commercial Book of Business Benchmark whic consists of Primary Care Physicians, Specialists, and Behavioral health Clinicians

Integrated Imaging Management Program Begins January 1


Effective January 1, 2013, Anthem National Accounts and BlueAdvantage Administrators of Arkansas will begin using an Integrated Imaging Management Program for outpatient diagnostic imaging procedures.  This program is for designated Anthem BCBS members, Walmart associates and Tyson team members, and their covered dependents throughout the United States.  Those members residing in the Montana service area will be included in this national care management program.
 
The program, administered by AIM Specialty HealthSM (AIM), includes clinical appropriateness review of advanced imaging services and assists members in finding a “best value” site for MRI and CT exams using the Blue Cross and Blue Shield Association’s National Consumer Cost Tool (NCCT) data set. 

There are three primary components included in the imaging management program described below:

  1. Clinical appropriateness review:  AIM will provide prospective clinical review for elective, outpatient CT, MRI, nuclear cardiology, PET and echocardiography exams.
  2. Provider transparency: During the clinical review process AIM will share NCCT cost information with the ordering physician’s office.
  3. Member transparency:  AIM will make outbound phone calls to members if there is an opportunity for members to maximize their benefits by selecting a different facility for their MRI or CT exam.  These conversations will be supported by the NCCT cost information as well.

Clinical Appropriateness Review  
For procedures scheduled on or after January 1, 2013, physicians ordering elective, outpatient diagnostic imaging exams for the members listed above will be asked to obtain an order number from AIM before scheduling the procedure.  These services include:

  • Computed Tomography (CT/CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)
  • Stress Echocardiography (SE)
  • Resting Transthoracic Echocardiography (TTE)
  • Transesophageal Echocardiography (TEE)

Imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and free standing surgery centers), urgent care centers, or 23-hour observations are excluded from this requirement.

BCBSMT physicians will find out about the program when checking benefits and eligibility.  Messaging will instruct the physicians to contact AIM to request or verify an order number one of two ways:

  1. Online through AIM’s ProviderPortalSM at www.aimspecialtyhealth.com/goweb or
  2. Via the toll-free telephone number displayed on the back of the member’s ID card,
    or direct to AIM at 1-866-688-1449.

The member also may call AIM to initiate the process.

Provider Transparency
To support national transparency efforts and through partnership with its Blue clients, these Blue Plans will be leveraging the NCCT cost values for Blue imaging providers.  During the clinical review process, we will be sharing MRI and CT costs with ordering providers in an effort to promote transparency and increase awareness. 

Member Engagement
Using the clinical appropriateness approval as the trigger, we also will be engaging members in their site-of-service selection through the Specialty Care Shopper℠ program.  When a CT or MRI/MRA exam is scheduled on or after January 1, 2013, a customer service specialist will proactively reach out to members to inform them of the imaging facility options available to them.  During this outreach, members will have an opportunity to maximize their health care benefits by selecting an alternative imaging facility.  Members will not be denied access to benefits if they decide to stay with their existing facility.  The goal is simply to provide members with information to make informed choices about their health care.

Anthem National Accounts and BlueAdvantage Administrators of Arkansas appreciate your assistance with the program for their members.  

The Next Generation of Medical Management


Blue Cross and Blue Shield of Montana (BCBSMT) would like to introduce you to the next generation of Case and Disease Management services available to our members. Care Coordination is a member engagement and advocacy program intended to achieve improved clinical outcomes, reduce health care costs, and address the individual needs of our members.  The term “Care Coordination” is often used interchangeably with “Care Management.” Our program takes a total population management approach, incorporating successful methodologies from traditional case management, disease management, and wellness models.

BCBSMT staffs our Care Coordination program with board-certified medical and behavioral health professionals. The team includes RNs, Certified Case Managers, Licensed Clinical Social Workers, and Licensed Clinical Professional Counselors with oversight from the Medical Director.  BCBSMT’s care coordinators perform many services, such as those below, for the members they support:

  • Validate eligibility for insurance and benefits limitations, exclusions, copayments, and deductibles
  • Assist with exploring alternative evidence based plans of care
  • Assist with exploring other alternative funding programs
  • Educate members and support systems about medical conditions
  • Answer phone calls from enrollees seeking information and solutions to problems
  • Assist with obtaining prior authorizations, precertification of hospital admissions, and appeals
  • Provide referrals and resources to guide members to in-network providers
  • Help members transition to lower levels of care

Internal referral:  BCBSMT members at high risk for future health problems are identified for the program based on clinical diagnoses, cumulative risk factors related to chronic or co morbid conditions and high-dollar claims.  The Care Coordination program focuses on altering health behaviors, changing risk profiles, and improving health care utilization outlook.  Care Coordinators help members understand and use their health insurance benefits wisely, manage their medical condition, and maximize the impact of their physician's treatment plan with the end goal of improving quality of life.

External referral: Health care providers are encouraged to refer their patients who are BCBSMT members to our Care Coordination program any time they believe their patient could be positively impacted by additional clinical and health benefit experts.

Care Coordination is a voluntary, confidential program available to members and/or their caregivers.  If you would like more information or would like to refer a patient, call 1.800.447.7828, Extension 6235.

Clinical Practice and Disease Management Guidelines Available Online

 

In May 2006, the Regional Quality Improvement Committee approved the implementation of the Institute for Clinical Systems Improvement Clinical Practice Guidelines for the MedicareBlue PPO plan administered by the BCBS Northern Plains Alliance.  The guidelines were developed using an evidence-based approach, which emphasizes the critical evaluation of scientific evidence rather than expert opinion or consensus.  Currently published guidelines include Adult Breast and Cervical Cancer Preventive Guidelines and Chronic Obstructive Pulmonary Disease (GOLD) Guideline.

In addition, MedicareBlue PPO also offers a heart failure disease management program based on the American College of Cardiology and American Heart Association’s 2005 guideline for the Diagnosis and Management of Chronic Heart Failure in the Adult.  The guidelines and disease management program are published in their entirety online at www.yourmedicaresolutions.com .

If you do not have Internet access and require a printed copy, please contact Kris Thompson at 406.437.6462.

Electronic Claims Reduce Cost and Accelerate Payment Turnaround Time 

 

Did you know that on average, 47,000 paper claims are submitted to Blue Cross and Blue Shield of Montana (BCBSMT) each month?  And did you know that you can receive payment within 7 to 10 days if you submit your claims electronically compared to 30 days via paper? 

If your office still submits paper claims, be assured that your decision to “Go Green” and send claims electronically will help BCBSMT pay your claims faster and reduce the amount of paper received and shredded every day. 

Every paper claim received by mail is sorted, batched, and then scanned into our claims processing system.  BCBSMT employs a team of claims verification analysts who then make sure the claim has been submitted appropriately before we begin applying benefits and make provider payments.  All paper claims are then shredded to keep private health information secure. 

While it is readily evident that submitting paper claims is expensive and cumbersome when considering the cost of paper, printing, and postage, your decision to convert to electronic claims will also save a huge amount of another less tangible, but equally valuable asset — time.  Time is spent entering information onto paper forms, printing the claim forms, mailing the claims, and waiting for payment or requests for additional information.  This time can add up to 30 days or more. 

The alternative to expensive paper claims processing is to submit an electronic claim without the cost of paper, printing, and postage, not to mention all the aggravating wait time.  On average, with electronic claims, payment is received within 7 to 10 days.  If you are registered with an electronic claims clearinghouse, your claims bypass the verification system and processing begins the day the claims are received.

For all providers who currently submit claims electronically, please note that if you are experiencing issues with your electronic claims, reverting to sending hard copy claims to BCBSMT does not speed up your payment.  In those instances, contact your claims clearinghouse to determine the cause of the problem and continue to submit claims electronically. 

Additionally, sending paper claims will not speed up payment of a previously submitted claim.  To find out the status of your claims, simply register with us at bcbsmt.com to see the status of your claims payment.  You may also determine eligibility and learn about member benefits.  You can also ask a question online in a safe and secure environment. 

To begin submitting electronic claims, log on to Health-e-Web at www.hewedi.com or call 1.877.565.5457.  We are confident you will quickly grow to appreciate the convenience and time and money saved through the use of electronic claims submission.

 

Tips For Submitting Medicare Crossover Claims

Medicare Part A (facility and institution Crossover claims billed on a UB04) and Part B (professional provider claims billed on a CMS-1500) are automatically sent from the Centers for Medicare and Medicaid Services, (CMS) regional office electronically. 

Blue Cross and Blue Shield of Montana (BCBSMT) sends an eligibility file to CMS who then matches the eligibility and sends those member’s claims back to BCBSMT. Crossover claims for Federal Employee Program (FEP) members are also sent to BCBSMT.

If the claims were received by Medicare  Then claims are crossed over to BCBSMT within 
 Electronically  14 days after the claims have left the Medicare
claims payment floor
 Hard copy/paper  29 days after the claims have left the Medicare
claims payment floor

Electronic ERA (835)

If Medicare is sending the claim via Crossover, the 2100 loop is used to name the crossover carrier.

NM101 = TT
NM102 = 2
NM108 = (AD, FI, NI, PI, PP, XV)
NM109 = Identification Code

Although Medicare may send claim and payment information to multiple secondary payers, the 835 does not permit identification of more than one of those secondary payers. When COB transmissions are sent to more than one secondary payer for the same claim, report remark code N89 in a claim level remark code data element.

Standard Paper Remit (SPR)
The SPR will include a Remittance Advice Remark Code, (RARC) of MA18 indicating the claim has been forwarded to a supplemental payer and will name BCBSMT as that payer.

Please do not send a hard copy claim with the Medicare EOB.

If your office has received notice of final processing from CMS and it states the claim has crossed over to BCBSMT;

 

The administrative cost of sending paper claims for you, the provider, and BCBSMT quickly adds up.

How can a patient get added to the Medicare Crossover file?
We have implemented a new process to ensure our members who have Primary Medicare Coverage, that their eligibility is transmitted to CMS so your claims will systematically cross to BCBSMT for secondary payment.

If you repeatedly have to manually submit paper claims for a particular member, call us to verify the member is on the crossover file.  It not, we can add him/her to this file.  If we have not yet loaded a HICN, or it is different than the one on the MEOB, we will review and load the appropriate information as indicated from Medicare.

What about other Secondary claims?
Secondary claims can also be submitted to BCBSMT electronically.  For more information, visit http://www.hewedi.com/  FAQ 1010 for electronic secondary instructions or call 877.565.5457.

NEW METHODOLOGY IMPLEMENTED FOR DENTAL COMPENSATION

Effective January 1, 2013, Blue Cross and Blue Shield of Montana (BCBSMT) is pleased to announce it is moving to a new methodology for compensation, Relative Values for Dentists (RVD), published by Relative Value Studies, Inc. (RVSI).  We are doing this so that we can quickly and accurately implement fair fee reimbursements based on the rapid advancements in dental technology. 

RVD is an accurate and comprehensive relative value system whose methodology develops a fee based on a relative unit to a set fixed allowance.  It reflects the practice of dentistry and is designed to provide a fair way of determining reimbursement for services rendered.  Through an agreement with the American Dental Association (ADA), the Current Dental Terminology (CDT) system is included in RVD.  The allowances for CDT codes with RVD values are calculated by multiplying the RVD value times the Dental Conversion Factor.  The January 1, 2013, BCBSMT Dental Conversion Factor will be $40.00.

BCBSMT is dedicated to the quality of its dental products and has recently filed new, more comprehensive dental programs encouraging diagnostic and preventive services (D&P).  Dental plan features include no deductible applied to D&P services and no allocation of D&P services to each member’s annual maximum.  Implants and limited cosmetic services will be standard covered benefits on all new plans.  We just received regulatory approval on these programs and believe that with these new dental programs, we will achieve a more competitive posture in the marketplace allowing us to channel even more members into our participating providers’ dental practices.

Below is a table of the top dental codes and the associated dental compensation for 2013.

If you are a current BCBSMT participating dental provider, we believe you will be very pleased with this updated compensation model.  If you are not a current participating dental provider with BCBSMT, contact Dental Programs Director for the state of Montana, Kathleen Vanuka can be reached at 406.437.6090, or 949.422.0683.




 

 

TriWest Creates Transition Web Page

On April 1, 2013, the TRICARE West Region contract will transition to and be managed by another contractor.  TriWest Healthcare Alliance (TriWest) has created a special web page to help providers understand the timing and key information about the TRICARE transition.

The Provider Transition Update Center is your home for specific information on important deadlines, online submission and status of referrals/authorizations and claims, claims issues resolution, your status as a TRICARE network provider, frequently asked questions (FAQs), and much more. 

Visit the site often because information is considered valid as of the publication date and may change as the transition progresses. Please refer to TriWest Provider Transition Update Center frequently for updates.

 
 
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