BlueCare Tennessee

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Topics

• PCP Assignment for Members

• Partnering for Quality Improvement

• Claims Billing Reminders

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PCP Assignment for Members

Goal: • Improve members’ health by making sure they visit

the same Primary Care Provider (PCP) for care.(Members can request an immediate PCP changewhile at the doctor’s office)

Action: • PCPs will only be reimbursed for care given to

members who are assigned to them or if the PCPis in the system as covering for the member’s PCP.

Timeline: • Implementation began Jan. 1, 2015 • Claim denials began Aug. 1, 2015

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Guidelines & Exclusions • Guidelines for Reimbursement:

– Member care from a PCP – Specialists are exempt – Applies to office and home (location codes 11 & 12)

• Exclusions (PCP to be paid in these situations): – Retro-eligible members – Dual-eligible members – Newborns 90 days old or younger – CPT

® Codes 99420 and 96110*

– Member sees a PCP within the same group or the covering PCP – Health Departments, Federally Qualified Health Centers and Rural

Health Clinics *CPT ®is a registered trademark of the American Medical Association

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Covering/On-Call Providers

All PCPs Must Have a Covering or On-Call PCP

PCPs in a Group or Practice: • All PCPs in the same practice WILL show as

“covering” for other PCPs in practice. • All PCPs under the same tax ID CAN show as

“covering” for other PCPs on request.

PCPs Not in a Group or Practice: • PCPs not in a group or practice CAN show as

“covering” for other PCPs on request.

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Covering/On-Call Providers

Ensure your covering information is correct:

• Call Provider Services at 1-800-924-7141, option 1

• Fax your covering provider listing on businessletterhead to: (423) 535-3066 or (423) 535-5808

• Mail your covering provider listing on businessletterhead to:

BlueCare Tennessee 1 Cameron Hill Circle Attention: Provider Network Enrollment 2.4 Chattanooga, TN 37402-0001

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PCPs Working In Other Settings

Goal: For members to visit same PCP to get consistentcare. We know that is not always possible. If you work with members not assigned to you, the location code on the claim will drive claims payments.

Make sure to include location codes on claims.

Location Description Location Code

Mobile Unit 15

Walk-In Retail Health Clinic

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Urgent Care Center 20

Federally Qualified Health Center (FQHC) 50

Public Health Clinic 71

Rural Health Clinic 72

Members who frequently receive care in these settings,without being assigned to the PCP, don’t have a single source they need to oversee their overall health.

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Member Assignments Online

Up-to-date member assignments are available through BlueAccessSM, including mobile devices.

Updates to Search Function: • Choose more than one Line of Business • Search for member listings by NPI or Tax ID • Formatting results:

• Ability to export data (Excel or pdf) • Additions: member phone number, plan ID,

effective and term dates of PCP assignment

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How to Submit PCP Changes • Have the member request the PCP Change while in your

office by calling Customer Service.

• E-mail PCP change requests to: IO-BluecarePCP_GM@BCBST.com

• Fax completed PCP Change Form to 1-888-261-9025 – Note: The effective date of PCP change is the

signature date on the form. – Access the form online:

bluecare.bcbst.com/forms/Member­Handbooks/Primary_Care_Provider_PCP_Change_Form_3.3.15.pdf

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Provider Communications

Notifications of PCP Assignment to Members: – In 2014 All Blues and TMA workshops – Monthly BlueAlertSM articles (started September 2014) – Education through Provider Services – On-hold messages – BlueAccess Messages – On bluecare.bcbst.com (FAQs) – Facebook posts – Focused outreach to providers with high volume of denials – Letters and emails to all PCPs in July 2015 – In 2015 All Blues and TMA workshops

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Member Communications

Member Notifications: – Quarterly newsletters (started 4th Qtr 2014) – Announced at community events – On-hold messages – Letters and phone calls to members who:

• Visit an unassigned PCP • See many unassigned PCPs • Request multiple PCP changes

– On bluecare.bcbst.com – Facebook posts – BlueAccess messages – Inbound calls

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Partnering for Quality Improvement • 2014 Patient Experience Survey Results:

– General complaint in all regions: appointment and office visit wait. – Opportunities to improve in:

• Regular care appointments with specialists • Urgent care appointments with specialists • Regular care appointments with pediatricians • Office visit wait times for PCPs and OB-GYNs

• Provider Administration Manual Requirements: Specialty Care for Adults and Children: Less than or equal to 30 days

Urgent Care for Adult and Children: Less than or equal to 48 hours

Children Preventive and TennCare Kids: Less than or equal to 3 weeks

Office Wait Times: Less than or equal to 45 minutes

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Partnering for Quality Improvement

• WE WANT TO HEAR FROM YOU:

– Please complete the provider surveys. They help us see where we can improve our services and where you’re satisfied.

– We want to know how you feel about claims processing, reimbursement, utilization management and communication.

– Check your mail for this one-page survey!

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Quality Improvement Help Us Close Gaps in Care!

Steps you can take to improve your patients’ health and help save lives:

– Encourage your patients to make office visits. – Provide preventive and chronic care screenings at

every appointment (based on age and gender.) – At each visit, tell your patients how to improve

their condition(s). – Schedule appointments and send reminders to

your patients.

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Quality Improvement

• Ensure your patients to receive preventive tests and screenings like: – BMI assessments – Cervical cancer screenings – Chlamydia screenings – Comprehensive diabetes care screenings – Colorectal cancer screenings – Mammography screenings – Immunizations (child and adolescent) – PAP tests

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Quality Improvement

• Remind your patients to take their medicines and follow-up with them.

• Schedule required follow-up appointments for patients after their hospital visits.

• See patients for postpartum care within the required timeframes post delivery.

• Make sure patients see you for well-care visits.

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TENNderCare Program Gets a New Name

TENNderCare is now called TennCare Kids!

• TennCare Kids is TennCare’s Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program for members under the age of 21.

To learn more visit: tn.gov/tenncare/section/tenncare-kids

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Language Assistance

Language doesn’t have to be a barrier.

Visit www.languageline.com as well as our resource desk for more information.

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Important Claim Updates/Reminders

• Budget Reduction/Impacts for July 2015

• Medline – New incontinence provider, effective August 2015

• Medical unlikely edits

• Observation charges

• Hysterectomy forms

• High-tech imaging

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Questions? • Visit our website at bluecare.bcbst.com

• Call Provider Service Line for administrative issues: – BlueCareSM 1-800-468-9736 – TennCareSelect 1-800-276-1978

• Submit prior authorizations through BlueAccessSM

• For prior authorization questions, call Utilization Management at 1-888-423-0131

• Visit our BlueCare Tennessee Resource Center

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