Embed Size (px)
Citation preview
Healthy Blue
2020 annual provider training
Agenda• Informational reminder• Contacts and resources• COVID-19 and telemedicine• Benefits• Behavioral health• Pharmacy and laboratory benefits• Claims submission tools• Credentialing• Quality• Marketing
2
What is new?• Behavioral health• Corrected claims• Telemedicine• COVID-19• Social determinants of health• Authorizations for newborns• Prior authorizations (PA) for newborns
3
Informational reminders
4
Cultural competency• Cultural competency is a set of congruent behaviors, attitudes and policies
that enable effective work in cross-cultural situations.• Cultural awareness is the ability to recognize the cultural factors, norms,
values, communication patterns/types, socioeconomic status and world views that shape personal and professional behavior.
5
Cultural competency skills• Listens to others in an unbiased manner; respects other points of view;
promotes the expression of diverse opinions and perspectives• Uses appropriate methods of interacting sensitively, effectively and
professionally with persons of all ages and lifestyle preferences from diverse cultural, socioeconomic, educational, racial, ethnic and professional backgrounds
• Recognizes the importance of the role cultural, social and behavioral factors play in determining delivery methods for public health services
6
Cultural competency skills (cont.)
• Takes into account cultural differences when developing and adapting approaches to problems
• Understands the dynamic forces contributing to cultural diversity• Understands the importance of a diverse public health workforce• Obtain no-cost continuing medical education credits through further
study of cultural competency topics, go to:– https://www.thinkculturalhealth.hhs.gov/education* or– www.HealthyBlueSC.com and select Providers to review
cultural competency training
7
Fraud, waste and abuseProviders are a vital part of the effort to prevent, detect and report Medicaid noncompliance, as well as possible fraud, waste and abuse:• You are required to comply with all applicable statutory, regulatory
and other Medicaid managed care requirements in South Carolina, including adopting and implementing an effective compliance program.
• You have a duty to Medicaid to report any violations of laws that you may be aware of.
• You have a duty to follow your organization’s code of conduct that articulates your commitment to standards of conduct and ethical rules of behavior.
• Visit www.HealthyBlueSC.com and select Providers to view more information about fraud, waste and abuse.
8
Reporting fraud, waste and abuse
If you suspect it, report it to your Compliance department or your sponsor’s Compliance Department:• The Compliance department will investigate and make the proper
determination.• To report fraud:
– Call Healthy Blue confidential fraud hotline at 877-725-2702 or email [email protected].
– Contact the South Carolina Department of Health and Human Services (SCDHHS) fraud hotline at 888-364-3224 or email [email protected].
9
Social determinants of health (SDOH)
• “Conditions in which people are born, grow, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequalities.” ~ World Health Organization
• SDOH:– Neighborhood and Environment– Health Care– Education– Economic Stability– Social and Community Context
• Use the CMS Screening Tool to help address social needs: https://innovation.cms.gov/Files/work sheets/ahcm-screeningtool.pdf*
10
SDOH (cont.)SDOH codes are represented in ICD-10-CM code categories Z55 to Z65 Neighborhood and Environment
See the full SDOH diagnosis code reference list by going to www.HealthyBlueSC.com and selecting Providers.
11
Code grouping Examples
Z55 Problems related to education and literacy Illiteracy/low level of literacy, schooling unavailable
Z56 Problems related to employment and unemployment
Unemployment, change of job, threat of job loss, military deployment status, sexual harassment on the job
Z57 Occupational exposure to risk factors
Occupational exposure to noise, radiation, dust, tobacco, toxic agents in agriculture, extreme temperature
Z59 Problems related to housing and economic circumstances
Homelessness, inadequate housing, discord with neighbors, extreme poverty, low income
Z60 Problems related to social environment
Adjustment to lifestyle transition, problems living alone, acculturation difficulty, social exclusion and rejection
Primary care access and availability
• Wait times must not exceed 45 minutes for a routine, scheduled appointment
• Walk-in patients with nonurgent needs should be seen or scheduled for an appointment
• 24-hour coverage by direct access or through arrangements with a triage system should be provided
12
Visit type: Availability standard:Routine visit Within four weeks
Urgent, Nonemergent visit Within 48 hours
Emergent visit Immediately scheduled upon presentation at a service delivery site
Specialist care access and availability
13
Visit type: Availability Standard:
Routine visit Within four weeks; maximum of 12 weeks for unique specialists
Urgent medical condition care appointment
Within 48 hours of referral or notification from PCP
Emergent visit Immediately upon referral
Contacts and resources
14
Provider education territory map
15
LowcountryTom [email protected] 803-382-5778
UpstateDonese [email protected] 803-382-5125
MidlandsJon [email protected] 803-382-5085
Pee Dee [email protected] 803-264-1414
CatawbaBunny [email protected] 803-264-2361
Behavioral Health (Entire State)Rikkia [email protected] 803-264-2954
CIMS/FQHCs (Entire State)Fancy [email protected] 803-264-3196
Healthy Blue contact informationWebsite: www.HealthyBlueSC.com and select Providers
Customer Care Center:• Phone: 866-757-8286 or TTY: 866-773-9634• Fax: 912-233-4010 or 912-235-3246• Hours: Monday through Friday, 8 a.m. to 6 p.m. ET
Utilization Management (UM) Department for Physical & Behavioral Health: • Phone: 866-902-1689• Fax: 800-823-5520• Hours: Monday through Friday, 8 a.m. to 5 p.m. ET
IngenioRx:• Prior authorizations: 844-410-6890
16IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Healthy Blue.
Healthy Blue contact information (cont.)
24/7 Nurseline:Phone: 866-577-9710, TTY: 800-368-4424
Case Management (CM) Department: Phone: 866-757-8286Hours: Monday through Friday, 8 a.m. to 5 p.m. ET
Disease Management (DM) Department:Phone: 888-830-4300 TTY: 800-855-2880Hours: Monday through Friday, 8 a.m. to 5 p.m. ET
Vision Service Plan (VSP):Phone: 800-615-1883Hours: Monday through Friday, 8 a.m. to 5 p.m. ET
Saturday, 10 a.m. to 3 p.m. ETSunday, 10 a.m. to 4 p.m. ET
17VSP is an is an independent company that provides vision network services on behalf of BlueChoice HealthPlan.
Healthy Blue websitewww.HealthyBlueSC.com and select Providers:• Commonly visited
areas:– Forms– Prior Authorizations
Tool– Operations manual– Bulletins
18
BlueBlast• Monthly provider focused newsletter.• Topics include:
– Important health plan updates– Healthy Connections – Announcements– Billing and claims information– Frequently asked provider
questions– Community outreach efforts and
upcoming events• Contact your Provider Education
representative to sign-up.
19
Prior Authorization Tool
20
www.HealthyBlueSC.com and select Providers:• Prior Authorizations Tool:
– Use for outpatient services only– Noncovered services may be
listed as requiring a prior authorization
– Always verify benefits coverage prior to rendering services.
Update: • Newborn authorizations are no longer
required for normal newborn deliveries:
– 48-hour stay for vaginal – 96-hour stay for C-section
• Newborn Notification Form is still required
LogistiCare — service area• Reservation
line is available Monday through Friday, 8 a.m. to 5 p.m. ET.
• Call at least three business days before medical appointment.
21
LogistiCare is an independent company that provides transportation services on behalf of BlueChoice HealthPlan.
COVID-19 and telemedicine
22
COVID-19Testing and visits associated with COVID-19 testing:• Waived cost shares — copays, coinsurance and deductibles:
– Includes visits to determine if testing is needed.– Tests samples may be obtained in various settings to include doctor’s
office, urgent care, emergency room (ER) or drive-thru testing. • Reporting, coding, billing and claims
– Follow the CDC updates for reporting, testing and specimen collection:https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html*
– Follow the CDC coding guidelines for diagnoses related to COVID-19:• https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-
Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf*• https://www.cdc.gov/nchs/data/icd/COVID19-guidelines-final.pdf*
23
COVID-19 (cont.)Testing and visits Associated with COVID-19 testing:• Telehealth (video and audio):
– Waived member cost shares for telehealth visits, including visits for mental health or substance use disorders.
– Telehealth providers can help get members to a provider for testing.– Facility providers — Report the CPT®/HCPCS code with the applicable revenue
code as an in-person visit and also append either modifier GT.• Telephonic-only care:
– Covered for in-network providers. • Cost shares will be waived for in-network providers only
– Out-of-network coverage will be provided where required. – Includes covered visits for mental health or substance use disorders and
medical services.. • Exceptions include chiropractic services and physical, occupational, and
speech therapies. • Resources:
– Visit www.HealthyBlueSC and select Providers to view the May 2020 BlueBlastfor more FAQ
24
Benefits
25
Covered benefitsNeed to know if a code is covered or what the reimbursement is for a code?
• https://www.scdhhs.gov/resource/fee-schedules:*– Fee schedules are listed by provider specialty type. – If the code appears on the SCDHHS fee schedule, it is
covered. – The reimbursement for each code will also be listed.– Medicaid managed care organization (MCO) plans are
required to offer at a minimum the same benefits as Healthy Connections Fee for Service (FFS).
26
Covered benefits (cont.)• https://www.scdhhs.gov/provider-manual-list:*
– Commonly visited areas:– Fee schedules– Manuals– Medicaid website
login– FAQs– Healthy Blue has a
wide variety of value-added benefits (VAB).
27
Copays
28
Benefit CopayPrimary care visits, RHCS and FQHCS $3.30
Specialists visits (including optometrists) $3.30
Medical equipment $3.40
Chiropractor $1.15
Home health (limited to 50 visits) $3.30
Prescription drugs (brand and generic) $3.40
Outpatient hospital $3.40
Inpatient hospital $25.00
Copay exceptionsMembers who are exempt from copay requirements:• Members under 19 years of age• Pregnant members• Members who are institutionalized• Members receiving emergency services in the ER• Members receiving Medicaid hospice services• Members of a federally recognized Indian tribe (exempt when
Catawba Service Unit in Rock Hill renders services and when referred to a specialist by Catawba Service Unit)
29
Copay exemptions (cont.)Services that are exempt from copay requirements:• Medical equipment and supplies provided by DHEC• Family planning services• End-stage renal disease services• Services provided at an infusion center• Services provided in urgent/minor care clinics
30
Durable medical equipmentHealthy Blue covers durable medical equipment (DME) when prescribed to preserve bodily functions or prevent disability:• Copay: $3.40 per item• Appropriate modifiers should be used to identify rental versus purchase
(new or used).• We require medical documentation from the prescribing doctor for DME
rentals. Most DME is dispensed on a rental basis only. • Rented items remain the property of the DME provider until the purchase
price is reached.• We may cover DME on a rent-to-purchase basis over a period of
10 months, unless specified otherwise at the time of UM review. • Authorizations• All custom-made DME requires authorization.• If unsure if authorization is required, contact UM at 866-902-1689.
31
Home health servicesHealthy Blue covers intermittent skilled nursing; home health aide services; physical, occupational and speech therapy services; and physician-ordered supplies:• Copay: $3.30• Members have a 50-visit limit on home health services with these
codes: 36415, S9128, S9129, S9131, T1021, T1028, T1030, T1031. • Authorizations:
– Healthy Blue requires prior authorization for all home health care.
– Services are authorized for a 30-day duration.– Contact UM to request authorization for home health services at
866-902-1689.
32
Physical, occupational and speech therapies
Healthy Blue covers outpatient services to include physical, occupational and speech therapy:• Copay: $3.30: adults only.• Members 21 years and older: limit of 75 combined visits/300 units per benefit
year• Members under 21 years of age: limit of 105 combined visits/420 units per
benefit year• Authorizations:
– Codes 97022, 97140, 97150, 97166, 97167 always require prior authorization.
– All other codes or any services beyond the benefit maximum will need medical review and prior authorization.
– Contact Utilization Management to request authorization for these services at 866-902-1689.
• To determine how many visits a member has used, please contact the Customer Care Center.
33
Physicals• Adult routine physicals are covered once every two years.• Sports physicals are covered under the following circumstances:
– Provided by an in-network primary care provider– Covered once per calendar year – Covered for members 6 to 18 years of age– Billed using CPT 99212 and diagnosis Z02.5– Can be billed in addition to a well-child exam and the well-child incentive– Reimbursement: $30
34
Routine vision services for members under 21
Routine vision services for Healthy Blue members under 21 years of age are covered through Vision Service Plan (VSP):• Copay — none for members under 19• Covered services:
– One routine eye exam every 12 months– One pair of eyeglasses (frames and lenses) and related fitting
every 12 months• When medically necessary, and approved ahead of time, other
services are covered during the 365-day period.• For authorization and information call VSP at 800-615-1883.
35
Routine vision services for members under 21 (cont.)
Healthy Blue covers routine vision services for members ages 21 and up through Vision Service Plan (VSP). • Copay — $3.30• Covered services:
– One routine eye exam every 12 months– One pair of eyeglasses (frames and lenses) and related fitting every 24
months. • When medically necessary, and approved ahead of time, other services are
covered during the 365-day period.• For authorization and information, call VSP at 800-615-1883.
36
VSP covered codes
37
Type of service Code
Exams and office visits 92002, 92004, 92012, 92014, 92015 (routine only)
Evaluation and management (E&M) services
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215
Consultations 99241, 99242, 99243, 99244, 9924
Urgent/emergency care 99050, 99051, 99056, 99058
Special ophthalmological services
76510, 76511, 76512, 76513, 76514, 76516, 76519, 76529, 92020, 92025, 920260, 92070, 92081, 92082, 92083, 92100, 92132, 92133, 92135, 92136, 92225, 92226, 92230, 92235, 92265, 92270, 92275, 92283, 92284, 92285, 92286, 92287, 95930
Surgical services 65205, 65210, 65220, 65222, 65430, 65435, 67820, 67840, 67938, 68020, 68040, 68761, 68801, 68815, 68840
Eye and ocular adnexa services 65205, 65210, 65220, 65222, 65430, 65435, 67820, 67840, 67938, 68020, 68040, 68761, 68801, 68810, 68815, 68840
Pathology and laboratory 83516, 83861, 87809
Medical vision servicesHealthy Blue covers medical vision services rendered by an ophthalmologist. Claims for these services are filed directly to Healthy Blue: • Copay: $3.30: 19 years and older
38
American Imaging Management ®(AIM)
AIM Specialty Health handles authorization requests on behalf of Healthy Blue for the following advanced imaging and cardiology services. AIM Specialty Health is a separate company providing some utilization review services on behalf of BlueChoice HealthPlan.
39
Advanced imaging and cardiology servicesComputed tomography scans (including cardiac)
Resting transthoracic tachocardiography
Magnetic resonance imaging (including cardiac)
Transesophageal echocardiography
Positron emission tomography scans (including cardiac)
Arterial ultrasound
Nuclear cardiology Cardiac catheterization Stress echocardiography Percutaneous coronary intervention
(PCI)
AIM (cont.)Effective October 1, 2020, Healthy Blue transitioned the Clinical Criteria for medical necessity review of certain outpatient rehabilitative services to AIM Specialty Health* Rehabilitative Service Clinical Appropriateness Guidelines:
40
Outpatient rehabilitative servicesPhysical therapy (CG-REHAB-04)
Occupational therapy (CG-REHAB-05)
Speech language pathology (CG-REHAB-06)
Resources:• Healthy Blue Bulletin — June 20:
– Transition to AIM Specialty Health Rehabilitative Services Clinical Appropriateness Guidelines:
• Access and download a copy of the current and upcoming guidelines
AIM (cont.)
41
AIM Specialty Health handles authorization requests on behalf of Healthy Blue for the following radiation oncology services.
1. Radiation oncology performed as part of an inpatient admission is not part of the AIM program. Radiation oncology providers are strongly encouraged to verify that authorization has been obtained before initiating scheduling and performing services.
Radiation oncology servicesBrachytherapy 3-D conformal therapy1 (EBRT) for bone metastases
and breast cancer Intensity Modulated Radiation Therapy
Hypofractionation for bone metastases and breast cancer when requesting EBRT and intensity modulated radiation therapy (IMRT)
Proton beam radiation Therapy
Special procedures and consultations associated with a treatment plan (CPT codes 77370 and 77470)
Stereotactic radiosurgery/stereotactic body radiotherapy
Image-guided radiation therapy
AIM (cont.)• If AIM authorizes the service, AIM will provide an order
number to the ordering provider:– AIM will send this approved order number to Healthy
Blue, who will assign an actual authorization number.• File the authorization number you receive from Healthy
Blue on the claim, and not the AIM order number. – Filing the AIM order number on the claim may result
in a denial of the claim.
42
AIM (cont.)• ProviderPortalSM is the fastest, easiest way to contact
AIM:– ProviderPortal offers a convenient way to enter your
authorization requests or check on the status of previous authorizations. Go to www.providerportal.com* to begin. Registration is required.
• For questions regarding online authorizations, contact the AIM ProviderPortal Support team at 800-252-2021.
43
BabyNetBabyNet is South Carolina’s early intervention system for infants and toddlers under 3 years of age with developmental delays or who have conditions associated with developmental delays:• BabyNet includes services for infants and toddlers ages 0 to 3
years.• All current Medicaid services are included in BabyNet.• For questions about BabyNet visit
www.scdhhs.gov/resource/babynet.*
44
Behavioral health
45
Behavioral health: covered services
• Inpatient services provided in a general acute care hospital and Institute for Mental Diseases (IMD)
• Professional psychiatrist services• Outpatient services provided by licensed independent practitioners
(LIPs), group practices, federally qualified health centers (FQHCs) and rural health clinics (RHCs), including psychiatrists and advanced nurse practitioners
• Substance abuse services provided by any of the Department of Alcohol and Other Drug Abuse Services (DAODAS) commissions.
46
Behavioral health: covered services (cont.)
• Autism services• Psychiatric residential treatment facility (PRTF) services• Rehabilitative behavioral health services (RBHS)• Opioid treatment program (OTP) • Institutes for mental disease (IMD)
47
RBHSRBHS services provided by network providers:• Licensed independent practitioners (LIPs) • South Carolina Department of Alcohol and Other Drug Abuse Services
(DAODAS) • South Carolina Department of Mental Health (DMH)• South Carolina Department of Education (DOE)
RBHS adult and child services that require a PA: • H2014, H2017, H2030, H2037, S9482 and H0038:
– Defined as RBHS codes by Healthy Blue – Prior authorization form (specific to your agency or the Rehabilitative
Behavioral Health Services Treatment Review and Authorization Request Form found on the website) in addition to diagnostic assessment, treatment plan of care, which includes services delivered
• Any additional clinical information the provider feels supports the request, including treatment updates if the diagnostic assessment is more than three months old
48All out of network providers require authorization for all services regardless of provider type.
Institutes for mental disease (IMD)
IMD are often referred as free-standing psychiatric facilities:• IMDs are covered for members ages birth to 21 years of age.• All IMD services require authorization.• If you have a member receiving IMD services, please contact our
Behavioral Health Utilization Review department at 866-902-1689, option 3.
• Certification of Need can be faxed to 877-664-1499.
49
Opioid treatment program (OTP) OTP are outpatient substance use treatment services for members who have an opioid use disorder and are receiving medication-assisted treatment and psychoeducational services:• There are no age restrictions for participation.• OTP services do not require authorization.• New procedure codes filed for OTP effective July 1, 2020:
50
Current code
New code
Service description Billing frequency
H0016 G2068 Medication assisted treatment (MAT), buprenorphine (oral) Bi-weekly
H0020 G2067 MAT, methadone Bi-weekly
H0047 G2077 Periodic assessment for MAT No Limitations
H0047 G2076 MAT assessment Once per Year
N/A G2069 MAT, buprenorphine (injectable) Once every 4 Weeks
N/A G2073 MAT, naltrexone Once every 4 Weeks
N/A G2074 MAT, no medication administered No limitations
Behavioral health resourcesThe following provider resources are available from Healthy Blue:• Clinical Practice Guidelines• Behavioral Health Outpatient Treatment Request form• Behavioral Health Data Sharing form• Psychological Testing Request form• Provider Guide• ASD Testing Authorization form• ASD Services Request form• PRTF Prior Authorization form• RBHS Behavioral Health Treatment Review and Authorization Request
form• RBHS Progress Note form• Dispute forms
View provider resources at www.HealthyBlueSC.com and select Providers.
51
Behavioral health credentialingCompanion benefits alternatives (CBA) coordinates credentialing for mental health practitioners:• The following forms are needed when submitting a provider for credentialing through
CBA:– Completed application (The CBA application rather than the SC Uniform
application)‒ Completed W9 form or appropriate IRS documentation:
• Letter 147C, CP 575 E or tax coupon 8109-C‒ Healthy Blue MCO Agreement:
• MDs/Dos = physician agreement, all others = ancillary agreement)‒ Disclosure of Ownership Statement‒ Copy of state license‒ Copy of Drug Enforcement Administration (DEA) license, if applicable‒ Medicaid number (required for network participation)‒ Proof of current malpractice coverage†
CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueCross HealthPlan.† Coverage minimums: Medical Doctors = JUA/PCF or $1,000,000/$3,000,000; All others = $1,000,000/$1,000,000
52
Behavioral health — Beacon Health Options
Beacon Health Options (BHO):• A large behavioral health organization that serves more the 36 million
people across the country. • Partnership combines Healthy Blue’s existing solid behavioral health
business with Beacon’s successful model and support services to create a comprehensive behavioral health network.
• Offers the best-in-class behavioral health capabilities and whole-person care solutions to help people live their best lives.
• No member or provider business changes:‒ Members: Continue to call the customer service number on the back of
their membership card or access their health plan’s website for online self-service.
‒ Providers: Continue to use the provider service contact information, websites and online self-service websites as part of their agreement with either Healthy Blue or Beacon.
Beacon Health operates as a wholly owned subsidiary of Anthem.53
Pharmacy and laboratory benefits
54
Pharmacy benefit manager —IngenioRx
IngenioRx is the pharmacy benefit manager (PBM) for prescription drugs and specialty pharmacy for Healthy Blue members:• Specialty prescriptions are covered by IngenioRx Specialty .• Certain specialty prescriptions, including compounds or
controlled substances, may require a new prescription to be sent to IngenioRx Specialty Pharmacy.
• IngenioRx Specialty Pharmacy • Phone: 833-255-0646
55
PBM — IngenioRx (cont.)Prior authorization (PA) process for retail medications and specialty drugs (pharmacy benefit):• You may use the following phone and fax numbers.
– Phone: 844-410-6890– Fax: 844-512-9005
PA process for medical injectables (medical benefit):• You may use the following phone and fax numbers for health plan Utilization
Management review.– Phone: 866-902-1689– Fax: 800-823-5520
For questions, please contact:• Pharmacy Member Services (24/7): 833-207-3118• Customer Care Center: 866-781-5094
56
Prescription authorizations• All medications will be limited to a one-month (maximum 31-day) supply at
all retail pharmacies.• If a medical condition warrants a greater quantity than the defined
one-month supply of medication, PA will ensure access to the prescribed quantity.
• Members should refer to their Evidence of Coverage (EOC) for benefit details, exclusions and limitations.
IngenioRx:• Prior authorizations:
– Phone: 844-410-6890
57
Pharmacy information and tools
58
• www.HealthyBlueSC.com:– Search for preferred formulary
drugs – Preferred drugs usually do
not require a PA– Nonpreferred drugs always
require a PA
Laboratory services• Healthy Blue has a preferred agreement with LabCorp for labs.
LabCorp is an independent company providing laboratory services on behalf of Healthy Blue.
• You can send anatomical pathology and cytology specimens to a local contracted pathology group or to LabCorp without precertification.
• Refer to the Provider Operations Manual for a complete list of labs that can performed in your office and billed to Healthy Blue.
• You can send STAT labs to a contracted hospital.• All other labs should be directed to LabCorp.• Certain laboratory services may require a PA, (for example, genetic
testing). Refer to the PA list to verify.
59
Clinical Laboratory Improvement Amendments
60
Claim format and elements
CLIA number location options
Referring provider name and NPI location options
Servicing laboratory physical location
CMS-1500 Must be represented in field 23
Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23.
HIPAA 5010 837 Professional
Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01
Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02.
To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic effective March 1, 2020. The CLIAcertificate identification number must be submitted in one of the following manners:
Claims submission tools
61
Identification card• Members are required to carry their Healthy Blue and Healthy Connections
ID cards.• ZCD Prefix – Always include when filing claims
62
Verifying eligibility• After being assigned to a health
plan, a member can switch plans within initial 90 days.
• Members may also lose eligibility at any time due to status change.
• There are several ways to check member eligibility:
• South Carolina Medicaid portal: https://portal.scmedicaid.com*
• Customer Care Center: 866-757-8286
• http://www.Availity.com* • SCDHHS Medicaid Provider
Service Center: 888-289-0709
63
Availity• Check claim status• Check member eligibility• View remittances• File claims: at no cost:
– Secondary– Corrected
• Claims disputes and appeals• Request PA via Availity:
Availity, LLC is an independent company providing administrative support services on behalf of Healthy Blue.
• Access Availity via Healthy Blue website
64
Availity (cont.)• File secondary claims• Select secondary, then enter:
– Patient information– Primary insurance plan
information– Primary insured subscriber
information• Learn more:
– Availity learning center • Coordination of benefits:
training demo. – Select help &
training > get trained
65
Availity (cont.)• File corrected medical claims:
– Go to billing frequency:• Select replacement of prior claim• Enter original payer control number
66
Claim submissionClaim filing limits (original claim):• All providers are allowed 365 days to submit claims.
Electronic data interchange (payer id 00403):• Preferred and fastest way to submit your claims:
– For set-up and information, call 800-470-9630.
Availity• Claims can be filed on the Availity Portal at no charge to the provider.
Hard copy:• If you need to file a hard copy claim or submit a corrected claim, please mail to:
Healthy BlueAttn: Medicaid ClaimsP.O. Box 100124Columbia, SC 29202-3124
67
Submit all Medicaid claims here.Important: Do not send Medicaid claims to commercial BCBSSC.
Corrected claims and requested medical records
Claim filing limits (corrected claim):• Effective August 1, 2020, participating and nonparticipating providers submit
corrected claims 12 months from the date of service.
Filing corrected claims:• Availity:
– There is a field titled Billing Frequencies. Select Replacement of prior claim.
– For set-up and information, call 800-470-9630.
Electronically:• Use loop 2300 and segment REF02 to indicate the original claim number• Use loop 2300 and segment CLM05-3 to indicate the claim frequency code.• 7 = replacement of a prior claim.
68
Corrected claims and requested medical records (cont.)
Hard copy: • If you need to submit a
corrected claim, please mail to: Healthy Blue
• ATTN: Medicaid ClaimsP.O. Box 100124Columbia, SC 29202-3124
Claims denied for requests for medical records:• We must receive medical
records within 60 days of the request.
69
Overpayment recovery addressOverpayment RecoveryHealthy BlueP.O. BOX Central 73651 Cleveland, OH 44193-1177
Overpayment Recovery(for overnight delivery)Healthy Blue – Central 736514100 W 150th St. Cleveland, OH 44135
70
Appeals• Appeals must be
received within 90 days from the remediation date to be considered for review.
• Submit appeals through Availity www.availity.com.*
• Include all pertinent clinical information along with the appeal.
• The Provider Appeal Request form is required if submitting appeal by paper.
71
Claims work flow
72
Contact you Provider Services representative, provide the name and call reference number
Call the Customer Care Center at 866-757-8286. Obtain name and call reference number.
Resolved Not Resolved
Access Availity for additional claims processing information.Resolved Not Resolved
Provider receives a denial/questions a payment.
8%
26%
29%
37%
No Authorization Member Ineligible Other Health Insurance Misc. R00000
Claims work flow (cont.)
73
Note: These percentages are based on the top four common denials.
The R00000 percentage includes:• Other carrier• Timely filing• Worker’s
Compensation coverage review
Note: Not all inclusive.
Credentialing
74
Credentialing and credentialing checklist
Visit www.SouthCarolinaBlues.com*
75
Credentialing questions• Call 800-868-2510, option 5• Email:
– Initial enrollment applications — [email protected]– Returning documentation — [email protected]– Provider demographic updates — [email protected]– Recredentialing — [email protected]
76
Provider validation – M.D. Check Up
• Electronic provider validation tool.• Available within My Insurance ManagerSM. • Allows you to verify your practice and physician demographic information
seamlessly. • Used to maintain our online provider directories, which members use to find
network participating primary care physicians, specialists, hospitalists and medical suppliers.
• Used to update your information in our systems to ensure accurate claims processing.
• Update information at any time; however, verification is required for each location on a quarterly basis as follows:– January 1 to March 31– April 1 to June 30– July 1 to September 30– October 1 to December 31
77
Provider validation – M.D. Check Up (cont.)
• Verify: Information shown is current and accurate. Update: Once a change has been made, update must be selected to confirm and accept the change.
• Remove location: Enter or select a date to indicate that a location shown in the Location List is no longer active or part of the organization.
• Remove practitioner: Enter or select a date to indicate that a practitioner is no longer participating with the specific location.
• Add practitioner: Add a practitioner to the specific location by using the Add Practitioner’s search function.
• View and edit: Access and edit location information (addresses, telephone number, fax number, hours of operation, etc.).
78
Quality
79
Quality practice consultant territory map
80HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Terry [email protected] 803-834-0168
Alfred Thomas, [email protected] 803-391-2452
Other Contacts:• HEDIS® Questions: [email protected]
• Physical Address:Healthy BlueAttn: Quality Department4101 Percival Rd., AX-E13Columbia, SC 29229
• Quality Fax:855-238-2257
Greenville
Lexington Richland
Orangeburg
Darlington
Lee
Sumter
CalhounClarendon
Florence
BarnwellBamberg
Hampton
Williamsburg
Marion
BerkeleyDorchester
Horry
ColletonAllendale
Charleston
Jasper
Dillon
Spartanburg
Anderson
Abbeville
Laurens
Saluda
Edgefield
Aiken
Cherokee
Oconee
NewberryFairfield
Union
York
Chester
Kershaw
Chesterfield
Pickens
Lancaster
North Carolina
Georgia
McCormick
Marlboro
Georgetown
Beaufort
Greenwood
Quality department contactsQuality is here to help!• HEDIS:
– Kim Chmiel at [email protected] – Trish Whitehead at [email protected]
• Care opportunity:– Devon Murphy at [email protected]
• Clinic days:– Danetta Gibbs at [email protected]
• Medical records for Care Opportunities during HEDIS off season, send records:– Email to [email protected]– Fax to 855-238-2257
81
Quality department• Telehealth• HEDIS• Provider Report Cards• Care Opportunities• CAHPS®
• MRCA
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
82
Telehealth guidance
83
Provider Benefits Member cost-share waived HEDIS measures now include
telehealth
Eligible Services Office or other outpatient visits Inpatient consultation Individual psychotherapy Pharmacologic Management Psychiatric diagnostic interview
examination and testing Neurobehavioral status examination Electrocardiogram interpretation and
report only Echocardiography
Patient Benefits Faster appointment, diagnosis and
treatment No risk of exposure for at-risk patients Increased access and availability to
specialists
Telehealth applications
84
• Live two-way interaction between a person and a provider using audiovisual telecommunications technology
Live video conferencing
• Interactive communication among multiple users at different sites (voice, video, and data)Teleconferencing
• Transmission of recorded health history through an electronic communications system to a practitionerStore-and-Forward*
• Personal health and medical data collection from an individual in one location transmitted to a different location (heart monitors, physical activity monitors)
Remote Patient Monitoring (RPM)
• Health care practice and education supported by mobile communication devices such as cell phones, tablets, and computers
Mobile health (MHEALTH)
What is HEDIS?Healthcare Effectiveness Data and Information Set:• Used to measure performance in the delivery of medical care and
preventive health services.• Covers 91 measures across the following five domains of care:
– Effectiveness of care– Access and availability of care– Patient experience– Utilization and relative resource use– Health plan descriptive information
85
What is HEDIS? (cont.)Healthcare Effectiveness Data and Information Set:• Evaluates adherence to both physical and behavioral health Clinical
Practice Guidelines (CPGs).• One component of a larger accountability system and complements the
NCQA accreditation program.• Hybrid medical record review is completed annually from January through
May: – A random sample of members are selected for review.– Healthy Blue requests medical records from providers.
86
What is HEDIS? (cont.)Healthcare Effectiveness Data and Information Set:• Annually:
– Members are randomly selected for review based on a predetermined sample size identified for each measure. This takes place during the annual data collection project performed each spring.
• Year-round:– Members who have not had a claim submitted for specific services may
be selected to assess barriers and provide information to providers (Care Opportunity reports).
• Compliance audit:– The Clinical Practice Consultant team pulls a stratified, random sample
of a provider’s panel for review of the medical record documentation standards.
87
Examples of HEDIS measures
88
Well care for children
• Well visits – From newborn to age 18:• Weight and BMI Percentile• Nutrition and Physical
Development• Anticipatory Guidance
• Childhood and adolescent immunization
• Lead Screening
Comprehensive diabetic care
• Hemoglobin A1c• Diabetic Eye Exam• Blood Pressure• New for 2020:
• Kidney Evaluation• One eGFR (Estimated Glomerular
Filtration Rate Lab Test• One UACR (Quantitative Urine
Albumin Lab Test• One Urine Creatinine Test
Examples of HEDIS measures (cont.)
89
Women’s health
• Prenatal and Postpartum Care• Chlamydia screening• Breast and cervical cancer screening
Behavioral health
• Antidepressant Medication Management• Follow-Up for Children Prescribed ADHD
Medication• Follow-Up After Hospitalization for Mental
Illness• Use of First-Line Psychosocial Care for
Children and Adolescents on Antipsychotics• Metabolic Monitoring for Children and
Adolescents on Antipsychotics• Initiation & Engagement of Alcohol and Other
Drug Dependence Treatment
Provider report cards Provider report cards identify the following:• Number of providers in the
practice• Total membership (current)• Total care opportunities in the
eligible population for HEDIS• Number of target members
needed to be seen to meet the specific National Committee for Quality Assurance (NCQA) percentile for that practice/for that measure
• Practice rate for that NCQA HEDIS measure
90
Care Opportunity reportsCare Opportunity reports include:• Members who have not
had any visits last year.• Members who are in need
of preventive service(s).• Current demographic
information (Healthy Connections).
• Legend for each of the measures on the Care Opportunity report.
91
CAHPS — opportunities for quality improvement
92
CAHPS — Adult Survey Opportunities
93
Opportunities Possible Solutions
Q22 — Rating of Specialist seen most often
Listen to patient concerns and spend adequate time with them Engage the patient in discussions about medications Avoid using medical jargon and technical language
Q24 — Customer Service provided need information or help
Ensure that representative are friendly and polite Resolve issues completely and follow up with members Ensure that representatives listen carefully and avoid
interrupting
Q18 — Rating of personal doctor Ensure that providers are informed about the patient’s relevant medical and person background
Remain up-to-date on medical advancements Connect with the patient on a personal level Reduce wait times in the office
Q9 — Ease of getting care, tests or treatment
Conduct a thorough assessment of the patient’s needs Treat patients with urgent issues promptly Provider care and service quickly Minimize wait times and communicate reasons for delays
Q5 — Made appointments for routine care at office or clinic
Schedule appointments within sufficient time frame Treat patients with great urgent issues promptly
Q4 — Got an appointment for urgent care as soon as needed
Schedule appointments within sufficient time frame Treat patients with great urgent issues promptly
Medical Records Compliance Audit (MRCA)
• MRCA starts during the summer after HEDIS• Audit locations with 200+ members• Review five random records for up to five providers• A contractual audit that reviews medical records for documentation
standards set by the state
94
Marketing
95
Marketing and Outreach team
96
PeeDee RegionJermaine Tart,Outreach Care Specialist Sr.Direct: [email protected]
Upstate RegionDavid Rojas, Outreach Specialist Sr.Direct: [email protected]
Midlands Region Melody Clark, Outreach Specialist Sr. Direct: [email protected]
Modified RegionDavid LiethenCommunity Relation RepresentativeDirect: [email protected]
BlueChoice HealthPlan is an independent licensees of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Heathy Connections
Lowcountry RegionErica Gattison, Outreach Specialist Sr.Direct: [email protected]
Marketing and Outreach management
97
Letitia Lindsay,Community Outreach ManagerDirect: [email protected]
Debbie Gasparro Marketing Specialist Direct: [email protected]
Jessica Hubbell,Director of Marketing and OutreachDirect: [email protected]
Social mediaMake sure to follow us!
98
fb.me/HealthyBlueSC* @CoachBlueSC
@HealthyBlueSC #HealthyBlueSC
Marketing and community outreachOur community partnerships are just a few examples of the way we go above and beyond the provision of basic health coverage.
99
Our focus
100
Connect members to a strong network
of Primary Care Physicians and
Specialty Providers
Continue to serve more than 140,000
members statewide
To help people get the medical care
they need and the respect they
deserve
Work with community and
faith-based organizations to
help our members find local resources
Redetermination• We help members maintain health care coverage through
awareness:– Renewing every 12 months from the date of enrollment.– Making sure addresses are up to date with Healthy Connections
if the individual has moved.– Fill out the Healthy Connections Annual Review Form completely
and accurately, and send it back before the due date given on the form.
• We educate the community on ways to do this such as:– Visiting www.scchoices.com* to make sure addresses are
updated.– Visiting the Healthy Connections Medicaid office for other
assistance.101
Extra benefits
102
Free one-time paid membership:• Pregnant moms, eligibility requirements
apply
Choice of….
$20 Lyft/Uber card, bi-annually
Or
Oil change, annually
Extra benefits (cont.)
103
Fruit and vegetable delivery:• Diabetic members receive up to two months• Eligibility requirements apply
Free adult vision:• Ages 21 and up• Annual eye exams• Glasses and frames every two years
Free diapers and car seat:• Up to 15 months of ages• Case of diapers (200 count)• Limited to no more than six, after well-child visits• Car seat - eligibility requirements apply
Extra benefits
104
Free GED ready assessment test:• Ages 17 & up
Free sports physicals:• Ages 21 to 18
Free headphones/earbuds:• Use for school/work computers or listen to music:
– Headphones for youths: K to 5th grades– Earbuds for youths: 6 to 12th grades
Extra benefits
105
Free Youth Explorer Program through Boy Scouts:• Youth: 3rd to 12th grades
Free Girls Scouts memberships:• Girls K to 8th grades
Discounts on Boys and Girls Club fees:• Only at participating clubs
Extra benefitsCommunity ResourceLINK:• Assistance with finding low to no-cost local
service for:– Housing– Education– Jobs– and more!
• Go to www.HealthyBlueSC.com and select Providers to view helpful organizations and agencies
• Enter a ZIP code • Select the type of service needed• Call Customer Care Center at 1-866-781-5094
(TTY 1-866-773-9634).
106
Extra benefitsOther Healthy Blue benefits include:• Free cellphone with monthly minutes data and texts• Free circumcisions up to 1 year of age• Free electric breast pump• Free prenatal program• Free Internet Essentials program/free Wi-Fi for two months• Free coupon booklet with discounts to local store• Free Med Sync program for same-day medicine refills• No copays for preventive/urgent care visits• No copays for some over-the-counter drugs with a prescription• Healthy Rewards reloadable gift card• Books for Babies• Discounts for Jenny Craig®
107
Healthy Blue Community Action Transit (C.A.T.)
• Coordinate transportation• Attend and event • Call the Customer Care
Center:– 866-781-5094 – TTY: 866-773-9634
108
G.A.M.E. P.L.A.N. for Health
109
Meet Coach Bluesm
Get regular checkups
Always eat fruits and veggies
Make healthy choices
Exercise daily
Play hard and safe
Learn ways to be healthy
Aim high and set goals
Never give up
G.A.M.E. P.L.A.N. for Health (cont.)
110
Thank you!2021 Annual Provider Training
111
112
* This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
www.HealthyBlueSC.comBlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email [email protected] December 2021
