Transcript Presentation Title

Servicing Out-of-Area
Blue Members
_____
Anthem Blue Cross and Blue Shield
3Q11 BlueCard® Webinar
for Virginia Providers
September 28, 2011
_________
Kathy Nixon, CMA (AAMA), CPC
Provider Network Manager
Provider Engagement & Contracting
[email protected]
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
Welcome !
Please . . .
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background noise
• Do not place this call on HOLD at any time
• Jot down and hold all questions; we will ask you to submit
your comments/questions via e-mail for response afterwards
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please close out your web connection and hang up your
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Thank You!
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
Disclaimer
The information contained in this WEBINAR
was current at the time it was published
or uploaded, but may be subject to change.
Anthem will continue to communicate
updates on an ongoing basis via our
provider newsletters and web portals.
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of
Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are
independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
Thank You!
Servicing Out-of-Area Members
Overview of Topics
• BlueCard® Program
• Submitting Claims
• Blue Products
• Claims Status
• Member ID Cards
• Claims Appeals
• Verifying Eligibility
• Contact Information
• Utilization Management
• Conclusion
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
4
Acronyms/Terms Used in this Presentation
• ANTHEM
Anthem Blue Cross and Blue Shield in Virginia
• BCBSA
National Blue Cross Blue Shield Association
• HOME
Plan from which member’s policy is issued
• HOST
Plan where member’s care was rendered
• IPP
Inter-Plan Programs
• ITS
Inter-Plan Teleprocessing Services
• MA
Medicare Advantage
• UM
Utilization Management
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
What is the BlueCard® Program?
• The national program that enables members of
one Blue Plan to obtain healthcare services
while traveling or living in another Blue Plan’s
service area; for example, a BCBS of Ohio
member travels to Virginia and receives care
from an Anthem provider.
• It links participating healthcare providers with
the independent Blue Cross and Blue Shield
Plans across the country and in more than 200
countries and territories worldwide, through a
single electronic network for claims processing
and reimbursement.
• It equips providers with one source, their local
plan (in this case Anthem Blue Cross and
Blue Shield in Virginia*) for claims submission,
claims payment/ adjustments, and issue
resolution for patients from other Blue Plans.
*Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
6
What is the Value to Providers of the
BlueCard® Program?
The BlueCard Program brings significant value to providers:
• The ability to serve the approximately 92.6 million
“Blue” covered members nationwide
• The ability to service all of these members
while contracting with only Anthem
– A one-stop shop for all claims-related activities:
submissions, inquiries, claim status, payment.
– Access to member eligibility,
benefits and pre-certification/
pre-authorization.
BlueCard® Eligibility Line
1-800-676-BLUE (2583)
– Reimbursement directly from Anthem* rather than
from the member. NOTE: Out-of-area members pay only those amounts indicated as “Patient
Responsibility” on provider’s remittance. Provider cannot bill these members for the difference
between billed charge and Anthem’s contractual allowance.
*Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
7
What are the different
Blue Products supported by
the BlueCard® Program?
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Products that the BlueCard Program Supports
Traditional / Indemnity
• Basic and/or supplemental hospital and medical/surgical benefits (basic,
major medical and/or add-on riders). In VA, this network is called
“Par” (for Participating) and the product is called “BlueCare”.
• Typically includes cost-sharing features
(e.g., deductibles, coinsurance or copayments).
• Provider is reimbursed according to Anthem’s Traditional/Indemnity
contract (our “Professional Provider” agreement) whose
reimbursement is the same as our PPO.
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9
Products that the BlueCard Program Supports
PPO – Preferred Provider Organization
• Significant financial incentive to members when obtaining services
from a designated PPO provider.
• No gatekeeper (primary care physician) required.
• No referrals required to access PPO providers.
• Provider is reimbursed according to provider’s PPO contract with
Anthem. This is our “Preferred Professional Provider” agreement
for our “KeyCare” PPO line of products.
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10
Products that the BlueCard Program Supports
EPO – Exclusive Provider Organization
• Members receive no benefits for care obtained outside the network except
emergency care.
• There is no primary care physician selection.
• Within the BlueCard Program, EPO benefits coverage is restricted to
services provided by BlueCard PPO providers.
• EPO products may have limited out-of-area benefits. The potential for
such benefit limitations is indicated on the reverse side of an EPO ID card.
• Provider is reimbursed according to Anthem’s PPO provider contract.
Anthem does not offer an EPO product in Virginia.
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Products that the BlueCard Program Supports
POS – Point-of-Service/Managed Care
• Highest level of benefits received when the member obtains services
from the primary care provider/group and/or complies
with referral authorization requirements for care.
• Benefits still provided when the member obtains care from any eligible
provider without a referral authorization, in accordance
with the terms of the contract.
• Provider is reimbursed according to Anthem’s PPO provider contract.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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Products that the BlueCard Program Supports
BlueWorldwide Expat®
• Provides medical coverage for active workers in U.S.-based companies
doing business abroad.
• Provides coverage for members enrolled in the BlueWorldwide Expat
program whenever they travel home to the U.S. for visits of up to 45 days.
– Claims incurred in the U.S. are processed like all other out-of-area
member claims.
• Provider is reimbursed according to provider’s PPO contract with Anthem.
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Products that the BlueCard Program Supports
Medicare Complementary/Supplemental (Medigap)
• Sold by private insurance companies to fill the “gaps” in original
Medicare Plan coverage to help pay for uncovered healthcare costs.
• Regulated under federal and state laws and are “standardized.”
• Most claims are submitted electronically directly from the Medicare intermediary
to the member’s Plan via the Medicare Crossover process.
Medigap does not include Medicare Advantage (MA) products as MA is a separate
program under CMS. Members with MA typically do not have Medigap because
under MA, Medigap policies do not pay deductibles, co-payments or other costsharing.
• Contracted and non-contracted providers are reimbursed the Medicare allowed
amount, based on where service was rendered, for Medicare covered services.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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How to Identify Blue Members
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15
Identifying Blue Members: Member ID Cards
Most Blue ID cards have a three-character alpha prefix (the first three
characters of the ID number). This prefix is vital for accurate claims
routing as it identifies the member’s Blue Plan.
Exceptions:
• Standalone dental ID cards
have no alpha prefix
• Standalone vision and
pharmacy ID cards have no
alpha prefix when delivered
through an intermediary
• Federal Employee (FEP) ID
cards have a single “R” prefix
*It is important for providers to ask members at each visit for their current
membership ID card, as new cards may be issued throughout the year.*
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Identifying Blue Members
Member ID Cards: BlueCard Program
• BlueCard members’ ID cards have a suitcase logo, which may
appear as empty or with “PPO” in the suitcase.
• This suitcase logo identifies the reimbursement level to the provider,
not the member’s benefits.
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Identifying Blue Members
Member ID Cards: BlueCard Program (continued)
The suitcase logo also provides information about the member:
• PPO in suitcase:
– The member is enrolled in a PPO or EPO product
(back of card may identify benefit limitations for EPO members).
– The provider is reimbursed at the Anthem PPO reimbursement
level.
• Empty suitcase:
– The member is enrolled in a Traditional/Indemnity, HMO or POS
product.
– The provider will be paid at the Anthem Traditional/Indemnity
reimbursement level.
– Note: Anthem’s reimbursement level is the same for
Traditional/Indemnity (or “Par”), and PPO, POS.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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Identifying Blue Members
Member ID Cards: Government Programs
Some Blue ID cards do not include a suitcase logo:
• Government-Wide Service Benefit Plan (also known as the Federal
Employee Program or FEP)
• Medicare Complementary/Supplement (also known as Medigap)
• Medicaid (claims are priced at the member’s state Medicaid rate)
• State Children’s Health Insurance Program (also known as SCHIPpayment is limited to the member’s state SCHIP reimbursement rate)
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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Identifying Blue Members
Member ID Cards: Medicare Advantage
• Providers can recognize Medicare Advantage
members by one of these logos on the ID card.
• The text “Medicare charges might apply” will
appear on either the front or back of the card.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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Medicare Advantage: Background
• Medicare Advantage (MA) is a government program under which
Medicare beneficiaries can opt out of traditional Medicare and enroll
with a private insurance carrier, such as a Blue Plan. Once a Medicare
beneficiary opts out of traditional Medicare and elects a Medicare
Advantage plan, the coverage (both primary and secondary
combined) is provided by the private insurance carrier.
• The MA member continues to pay their Medicare Part B premium and,
if applicable, a premium to the private insurance carrier.
• MA products must cover, at a minimum, the same services as original
Medicare (Parts A and B) and often offer additional benefits like vision
and dental, and/or may cover deductibles/coinsurance.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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Medicare Advantage: Claims and Reimbursement
• Blue Medicare Advantage (MA) claims are sent by the provider
to Anthem.
• Claims where a Medicare Advantage PPO member was treated by a
Medicare Advantage PPO provider are considered MA PPO in-network
claims and are reimbursed according to Anthem’s MA PPO contract
with the provider, both for local MA members and other out-of-area Blue
MA members. Contact your local Anthem Network Manager for
contracting information.
• Non-network MA providers’ claims are priced at the standard Medicare
allowed amount based on where services are rendered.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
22
Identifying Blue Members (continued)
Member ID Cards: BlueWorldwide Expat
• Providers may see patients enrolled
in the BlueWorldwide Expat product:
– Medical coverage for employees
of U.S. companies who are
based abroad.
– Includes coverage when employees
temporarily return to the U.S. for up
to 45 days per visit.
• ID cards include the three-character
alpha prefix.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
23
Identifying Blue Members
Member ID Cards: International Licensees
• Occasionally providers may see ID cards from members
of International Licensees.
• International Licensees include:
– U.S. Virgin Islands
– Uruguay
– Panama
• ID cards from these Licensees
include:
– Three-character alpha prefix
– Possibly a benefit product logo
(e.g., suitcase)
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Identifying Blue Members
Member ID Cards: Limited Benefit Products
• A limited benefit product is a healthcare plan that has an annual maximum benefit
of $50,000 or less per covered member, not including amounts, if any, for dental or
vision benefits.
• Members who have Blue limited benefit product coverage carry ID cards that may
have one or more of the following indicators:
– One of these product names:
› InReach, MyBasic or some other non-Blue name
– A green stripe at the bottom of the card.
– A statement either on the front or the back of the ID card stating this is a limited benefit product.
– A black cross and/or shield to help differentiate it from other ID cards.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
25
Identifying Blue Members
Member ID Cards: CDHC & Healthcare Debit Cards
• Members with Consumer-Directed Healthcare (CDHC) plans often carry healthcare debit
cards to allow them to pay for out-of-pocket costs using funds from their Health
Reimbursement Arrangement (HRA), Health Savings Account (HSA) or Flexible
Spending Account (FSA).
• Some ID cards are standalone debit cards that cover eligible out-of-pocket costs; others
also serve as the member’s ID card.
• In some cases, the card will display the Blue Cross and Blue Shield trademarks, along
with the logo from a major debit card (e.g., MasterCard®, Visa®).
• The cards include a magnetic stripe allowing providers to swipe the card at the point-ofservice and collect the member cost-sharing amount.
Standalone Debit Card:
Combined Debit Card / Member ID Card:
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How to Verify a
Blue Member’s Eligibility
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
27
Verifying Eligibility
The member’s Blue Plan (HOME) maintains member eligibility information.
• Providers may verify member eligibility and coverage information by calling
the BlueCard Eligibility Line: 1-800-676-BLUE (2583) or electronically through
Anthem’s secure portal, Point of Care.
1-800-676-BLUE (2583)
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
Electronically through Anthem
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How to Obtain Information on a Member’s
Utilization Management Protocols:
Pre-certification / Pre-Authorization
and/or Medical Policy
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
29
Utilization Management
• The member’s Plan maintains their utilization management information, including any
applicable pre-certification/pre-authorization requirements and medical policy.
• For out-of-area members (commonly referred to as “BlueCard members”) obtaining
pre-certification/pre-authorization is ultimately the member’s responsibility; however,
most providers coordinate this on the member’s behalf.
• Providers can obtain pre-certification/pre-authorization information when calling the
BlueCard Eligibility Line: 1-800-676-BLUE (1-800-676-2583) to verify eligibility
• Providers also have access to the member’s Plan’s general pre-certification/preauthorization requirements through the Medical Policy and Pre-certification/Preauthorization “Router” found on the open provider portal of Anthem’s website.
– Enter the middle blue “tout” on the left of any screen; click on either option for “out of area” and
then enter the alpha prefix:
http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/va/f1/s1/t1/pw_b147992.htm&state=va&lab
el=Coverage%20%26%20Clinical%20UM%20Guidelines,%20and%20Pre-Certification%20Requirements
– Click “continue” and this will route provider to that member’s plan’s website where their policy and
UM requirements reside (provider may view but cannot perform the auth request from here)
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
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31
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
EXAMPLE “XYZ”
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
EXAMPLE “XYZ” takes you to BCBS of Michigan where
you can continue to view medical policy/precert info
or just use this functionality to learn the HOME plan
for prefixes you cannot identify.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
How/Where to Submit Claims for
Blue Members
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
35
Submitting Claims
To avoid unnecessary claim delays, providers need to:
• Submit claims to Anthem* and use appropriate coding as instructed by
Anthem. (As the local or HOST Plan, our coding, billing guidelines, and contractual
pricing applies, whereas the member’s HOME Plan governs benefits and medical
management requirements.)
• Electronically submitted claims (837s) will come into our gateway and be
routed via ITS to the member’s plan; Paper claims should be mailed to P. O.
Box 27401, Richmond, VA 23279
• Always submit claims with only valid alpha prefixes.
• Include Other Party Liability (OPL) information on the claim if there is an
indication of more than one payer.
• Send medical records timely and as instructed by Anthem (wait for our letter
requesting the specific records needed)
• Do not send duplicate claims.
*Exception is in Northern VA when treatment is rendered in the CareFirst Service Area. DETAILS ON NEXT TWO SLIDES:
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
36
If Your Office
Location where
patient is treated
is in

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc.
An independent licensee of the Blue Cross and Blue Shield Association.
® Registered marks Blue Cross and Blue Shield Association.
SERVICE AREA
(West/Outside of
Route 123)
And, Your
Provider
Contract
Status (by
network) is:
#1
#2
#3
#1
SERVICE AREA
(East/Inside of
Route 123)
#2
#3
For
ANTHEM (VA)
cardholders,
For
CareFirst (DC)
cardholders,
For cardholders
of all other
Blues
SEND CLAIMS TO:
SEND CLAIMS TO:
SEND CLAIMS TO:
ANTHEM
ANTHEM
ANTHEM
ANTHEM
CAREFIRST
ANTHEM
ANTHEM
CAREFIRST
ANTHEM
ANTHEM
CAREFIRST
CAREFIRST
ANTHEM
CAREFIRST
CAREFIRST
CAREFIRST
CAREFIRST
CAREFIRST
YES w/ VA
NO w/ DC
YES w/ VA
YES w/ DC
NO w/ VA
YES w/ DC
YES w/ VA
NO w/ DC
YES w/ VA
YES w/ DC
NO w/ VA
YES w/ DC
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
Anthem’s
Service
Area
CareFirst’s
Service
Area
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
How to Verify Claim Status
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39
Verifying Claim Status
• Allow Anthem 30 days for claims processing before following up.
• For Medicare Crossover claims, allow 30 days from when you submitted
the claim to Medicare before following up on the claim. Do not submit a
MedSup claim to Anthem before receiving a Medicare remittance
notice.
• Check claims status through Anthem’s website via Point of Care or by
calling the Anthem Provider Call Center at 1-800-533-1120 and follow
the appropriate prompts (the member’s ID # prefix will route inquiry to
our BlueCard department)
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
40
Claim Appeals Process
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41
Claim Appeals
• Providers in VA who wish to communicate about a processed claim must use
the Anthem “Claim Information / Adjustment Request Form #151”
– Electronically through the Point of Care secure portal
•
•
Using the Claims Inquiry function for a specific claim will automatically transfer
the claim’s demographics directly to the #151 where the provider can just enter
their remarks/comments and submit online, if no supporting documentation is
required.
The response will be returned online in the POC 151 section.
– Manually by downloading a blank copy from the open portal under
Answers @ Anthem, Tools & Resources, then Provider Forms
• Anthem’s direct link to our claims appeals/disputes processes is found online
under Answers @ Anthem, Tools & Resources, Claims:
http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/va/f4/s2/t0/pw_b
147825.htm&state=va&rootLevel=3&label=Claims&state=va&rootLevel=3
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42
Contact Information
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43
Contact Information
Telephone: (800) 533-1120; Select “2”
and follow prompts – member’s ID prefix will
route you to our local BlueCard area.
EDI Solutions HELP DESK:
Phone: (800) 991-7259; Fax (804) 354-2529
E-mail: [email protected]
Live Chat: anthem.com/edi
All Mail / Correspondence:
P. O. Box 27401, Richmond, VA 23279
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
SUMMARY: Reminders for Providers
Anthem is your “one-stop shop” for all BlueCard claim inquiries.
Contact Anthem*
for all claim
inquiries.
Utilize electronic
services at
Anthem’s Point
of Care secure
portal
Take advantage of
educational
opportunities.
Submit claims to
Anthem*
*Exception is in Northern VA when treatment is rendered in the CareFirst Service Area.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.
45
Thank You!
This concludes our WEBINAR program for the 3rd quarter of
2011. We hope you found the information helpful and that your
time has been well spent.
If you wish to comment about your experience today and/or if
you have questions specifically regarding today’s topic, please
submit an e-mail with “Anthem 9/28/11 Webinar: BlueCard”
in the subject line to: [email protected] and be sure to
include your detailed contact information so we may reply back to you
appropriately.
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of
Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are
independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
A presentation of the Blue Cross and Blue Shield Association. All rights reserved.