december 5, 2011 inside this issue: s-11-11 reminder...the ancillary claim filing rules apply...
TRANSCRIPT
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
December 5, 2011 S-11-11
The Blue Shield Report is
published by the professional relations department of Blue
Cross and Blue Shield of Kansas.
OUR WEB ADDRESS: http://www.bcbsks.com
Ann Dunn Communications Coordinator
Questions: Contact your professional relations representative or the professional relations hotline in Topeka at 785-291-4135 or 1-800-432-3587.
Acknowledgement: Current Procedural Terminology (CPT®) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. Applicable ARS/DFARS Restrictions Apply to Government Use.
Inside This Issue:
Reminder
HIPAA 5010 Deadline is Looming ..................................... Page 2 Availity is Coming to Kansas in 2012 ................................. Page 2 Quality-Based Reimbursement Program (QBRP) Begins
Jan. 1, 2012 ...................................................................... Page 2
Updates
FEP Benefits for 2012 ....................................................... Page 3 State of Kansas Benefits for 2012 ..................................... Page 3 Where do Labs, DME and Specialty Pharmacy Providers
File Blue Claims? .............................................................. Page 3 Professional Relations Hotline is now “Provider Network
Services” ........................................................................... Page 5 Centralized Network Enrollment ........................................ Page 5 Annual Data Verification .................................................... Page 6 Credentialing Requirements .............................................. Page 7 Web Changes – Medical Policy ......................................... Page 7
Pharmaceuticals
Formulary Update.............................................................. Page 8 Prescription Drug Changes for 2012 ................................. Page 8
TRICARE
HIPAA 4010 Cutoff Date Coming Soon ............................. Page 9 A Closer Look at Balance Billing ...................................... Page 10 Secure Provider Website Users Can Now Submit
Attachments with Claims ................................................. Page 10 Emergency Care vs. Urgent Care – It Pays to Know the
Difference ........................................................................ Page 11 Right of First Refusal – Why, How, and Important Points
To Remember ................................................................. Page 12
Workshop Opportunities
2012 Workshops ............................................................. Page 13
December 5, 2011 Blue Shield Report S-11-11 Page 2
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Reminder
HIPAA 5010 Deadline is Looming January 1, 2012 – You MUST be ready to send and receive HIPAA 5010 transactions!
All electronic transactions are impacted: Claims – 837 Remittance – 835 Eligibility & Claims Status – 27X
BCBSKS is accepting production HIPAA 5010 transactions. 277CA – New Claims Acknowledgement replaces Claims Confirmation Report. For more information visit the HIPAA 5010 information on the BCBSKS Web site.
http://www.bcbsks.com/CustomerService/Providers/EDI/hipaa5010/index.htm You may also call the EDI Help Desk with any questions, 1-800-472-6481.
WHAT IS YOUR STATUS???
Availity is Coming to Kansas in 2012 Blue Cross and Blue Shield of Kansas is proud to offer our contracting providers improved Web self-service functionality and usability by partnering with the Availity® Health Information Network. Beginning Jan. 9, 2012, contracting providers can use the Availity portal for the following transactions for Blue Cross and Blue Shield members in Kansas:
• Eligibility and benefits verification • Claim status inquiries
Providers who require other online services, such as pre-certification, will be re-directed to the secure section of the BCBSKS Web site through a single sign-on process.
For more information, including an online demonstration, please visit www.availity.com Quality-Based Reimbursement Program (QBRP) Begins Jan. 1, 2012
Just a reminder that claims filed after December 31, 2011 with dates of service January 1, 2012 will be eligible for additional reimbursement as outlined in the 2012 CAP mailing, the Blue Shield Report S-8-2011, and the Blue Shield Report S-9-2011. Providers are encouraged to read these materials to determine their eligibility and submit their attestations online through the Web site. Not certain if you qualify? Submit the attestation and we will verify and confirm your
eligibility and applicable incentive (Tier I and/or Tier II) back to you via e-mail.
December 5, 2011 Blue Shield Report S-11-11 Page 3
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Updates FEP Benefits for 2012 The FEP group renews on January 1, 2012. Benefit information can be located at the following link: http://www.fepblue.org/. Please review information for any changes. State of Kansas Benefits for 2012
The State of Kansas group renews on January 1, 2012. Benefit information is available on our Web site at: http://www.bcbsks.com/CustomerService/Members/State/index.htm. Benefit Plan C is new to BCBSKS, and is a qualified high deductible health plan.
Where do Labs, DME and Specialty Pharmacy Providers File Blue Claims? Generally, as a healthcare provider you should file claims for your Blue Cross and Blue Shield patients to the local Blue Plan. However, there are unique circumstances when claims filing directions will differ based on the type of provider and service. Ancillary providers are Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies and Specialty Pharmacy providers. The local Blue Plan as defined for ancillary services is as follows:
Independent Clinical Laboratory (Lab) The Plan in whose state* the specimen was drawn.
Durable/Home Medical Equipment and Supplies (DME) The Plan in whose state* the equipment was shipped to or purchased at
a retail store.
Specialty Pharmacy The Plan in whose state* the Ordering Physician is located.
*If you contract with more than one Plan in a state for the same product type (i.e., PPO or Traditional), you may file the claim with either Plan. 1. The ancillary claim filing rules apply regardless of the provider’s contracting status with the Blue
Plan where the claim is filed. 2. Providers are encouraged to verify Member Eligibility and Benefits by contacting the phone number
on the back of the Member ID card or call 1-800-676-BLUE, prior to providing any ancillary service. 3. Providers that utilize outside vendors to provide services (example: Sending blood specimen for
special analysis that cannot be done by the Lab where the specimen was drawn) should utilize in-network participating Ancillary Providers to reduce the possibly of additional member liability for covered benefits. A list of in-network participating providers may be obtained by contacting http://www.bcbsks.com/ProviderDirectory/index.htm
4. Members are financially liable for ancillary services not covered under their benefit plan. It is the
provider’s responsibility to request payment directly from the member for non-covered services.
December 5, 2011 Blue Shield Report S-11-11 Page 4
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Where do Labs, DME and Specialty Pharmacy Providers File Blue Claims? continued 5. If you have any questions about where to file your claim, please contact Customer Service, 800-
432-3990 or 785-291-4180, or e-mail [email protected] at Blue Cross and Blue Shield of Kansas.
Provider Type
How to file
(required fields)
Where to file
Example
Independent Clinical Laboratory (any type of non hospital based laboratory) Types of Service include, but are not limited to: Blood, urine, samples, analysis, etc.
Referring Provider: Field 17B on CMS 1500 Health
Insurance Claim Form or Loop 2310A (claim level) on the
837 Professional Electronic
File the claim to the Plan in whose state the specimen was drawn* * Where the specimen was drawn will be determined by which state the referring provider is located.
Blood is drawn* in lab or office setting located in Kansas. Blood analysis is done in Oklahoma. File to: Blue Cross and Blue Shield of Kansas. *Claims for the analysis of a lab must be filed to the Plan in whose state the specimen was drawn.
Durable/Home Medical Equipment and Supplies (D/HME) Types of Service include, but are not limited to: Hospital beds, oxygen tanks, crutches, etc.
Patient’s Address: Field 5 on CMS 1500 Health
Insurance Claim Form or Loop 2010CA on the 837
Professional Electronic Submission.
Ordering Provider: Field 17B on CMS 1500 Health
Insurance Claim Form or Loop 2420E (line level) on the
837 Professional Electronic Submission.
Place of Service: Field 24B on the CMS 1500
Health Insurance Claim Form or
Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions.
Service Facility Location Information: Field 32 on CMS 1500 Health
Insurance Form or Loop 2310C (claim level) on the
837 Professional Electronic Submission.
File the claim to the Plan in whose state the equipment was shipped to or purchased in a retail store.
A. Wheelchair is purchased at a retail store in Kansas. File to: Blue Cross and Blue Shield of Kansas.
B. Wheelchair is purchased
on the internet from an online retail supplier in Florida and shipped to Kansas. File to: Blue Cross and Blue Shield of Kansas.
C. Wheelchair is purchased
at a retail store in Florida and shipped to Kansas. File to: Blue Cross and Blue Shield of Florida.
Specialty Pharmacy Types of Service: Non-routine, biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the member’s Plan’s Specialty Pharmacy formulary. Include, but are not limited to: injectable, infusion therapies, etc.
Referring Provider: Field 17B on CMS 1500 Health
Insurance Claim Form or Loop 2310A (claim level) on the
837 Professional Electronic Submission.
File the claim to the Plan whose state the Ordering Physician is located.
Patient is seen by a physician in Kansas who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Oklahoma where the member lives for 6 months of the year. File to: Blue Cross and Blue Shield of Kansas.
December 5, 2011 Blue Shield Report S-11-11 Page 5
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Professional Relations Hotline is now “Provider Network Services” The company recently installed a new call center platform that will allow enhanced call center services in the future. This was an opportunity to evaluate the hotline and streamline some of the internal processes that service provider calls. The Professional Relations Hotline has not made changes to the call center since March of 2005. The first enhancement you will notice is the greeting has changed to “Provider Network Services” and a new female voice now introduces the call center options. There are two changes to the option menu: (1) Option 9 allows callers to
enter their party’s extension, and (2) Option 5 has been added for workshop registration. Additionally, functions within the call center have been realigned to better serve our network providers. Here is a rundown of the complete menu options: Option 1 – Provider Service Representatives assist providers with correct completion of medical (CMS HCFA 1500) and dental (ADA) claim forms to include coding and billing. They are also available to assist you with questions pertaining to provider policy, BCBSKS business procedures and newsletter content as needed.
Option 2 – Callers needing assistance with BCBSKS claim status, adjustment, or review of a claim are routed to our Customer Service Center (CSC) for handling. Callers should have the member’s ID number available.
Option 3 – Provider Network Enrollment for BCBSKS and TRICARE – Network Enrollment Specialists respond to provider contract and application requests and assist providers with determining network eligibility. Network Enrollment Specialists receive and process all provider applications and assist with maintenance requests. Network Enrollment and maintenance requests can also be initiated by completing the Provider Network Enrollment Request form or the Provider Change of Information form on our Web site as applicable.
Option 4 – TRICARE network questions – The TRICARE Network Support Representative is available to assist providers with navigating and making best use of the TriWest.com Web site for self service. TRICARE Network Support also assists the Military Treatment Facilities with questions pertaining to network providers.
Option 5 – Workshop Registration – Assistance will be provided to register for a workshop, advise of upcoming workshops and confirm any registrations. Workshop registration can also be done via the www.bcbsks.com Web site. Centralized Network Enrollment Network Enrollment in Option 3 of the Provider Network Services call center carries the majority of the changes impacting the provider community. Network Enrollment and maintenance for all Kansas existing and new providers has been moved to Topeka. Dedicated Network Enrollment Specialists respond to provider contract and application requests for BCBSKS and TRICARE. When contracts and applications are received the network enrollment specialist will process the packet and contact the provider to obtain missing information when necessary.
December 5, 2011 Blue Shield Report S-11-11 Page 6
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Centralized Network Enrollment, continued Providers need to begin today contacting the Provider Network Services call center, option 3, for all contract and application requests or utilize the forms available on our Web site. The form link is provided below for your convenience. http://www.bcbsks.com/CustomerService/Forms/pdf/15-481_ProvNetEnrollReq.pdf It is our intent to continue to evaluate and implement changes that provide “best in class” services to our network providers.
Provider Information Change Form http://www.bcbsks.com/CustomerService/Forms/pdf/15-141_ProvInfoChange.pdf An updated provider data change form has been added to the Web site. Providers are encouraged to use this form to communicate updates to provider information. The use of this form by the provider community will assist with the processing of the updates and eliminate calls to provider offices clarifying updates received in other formats.
Annual Data Validation Maintaining an accurate provider file is an ongoing effort that requires everyone to be involved and in tune to when and what updates need to be communicated. Data accuracy audits are conducted by the Blue Cross and Blue Shield Association as well as TriWest. Checking the provider directories for both BCBSKS and TRICARE for each provider in the practice is one way to be in tune with how providers are being presented to the public. What appears in the directory is the most current information you have provided on your providers. When information in provider directories changes, access to your practice by members is impacted. Therefore, timely communication of the updates is essential to maintain accurate directories for members. At a minimum, please update when changes are made to any one of the following: Provider name Practice name Practice location
or when adding a practice location Mailing address Scheduling telephone number Medical fax number Tax ID number Specialty Do not hesitate to tell us a provider has left your group or practice. The claims for the terminated provider will continue to be processed without delay even when the provider has been termed from the directory. The Annual Data Validation exercise will commence early January 2012. This year we will be asking providers to view the Web site directories for accuracy on each provider rather than reviewing stacks of data filled forms. To confirm that provider data has been reviewed by someone in the office, a postage paid postcard will be sent to each billing NPI to complete and return to our office. Provider groups with greater than 30 providers will be sent a spreadsheet of their provider data for review and response. Further details will be included in the January mailing.
December 5, 2011 Blue Shield Report S-11-11 Page 7
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Credentialing Requirements Blue Cross and Blue Shield of Kansas credentialing staff hosted a credentialing workshop in Topeka and Wichita this fall. We were honored to have Christy Stroup, Senior Sales and Business Development Manager from the Council for Affordable Quality Healthcare (CAQH) who spoke about the enhancements to the CAQH application and instructions. The purpose of the workshop was to provide education related to TRICARE credentialing requirements, the CAQH application, and give an overview of how BCBSKS credentialing staff processes providers’ applications. It is important for the medical office staff to understand how the provider’s CAQH application is processed and how maintaining current information on the provider’s application ultimately streamlines the process of credentialing and recredentialing the provider. Participants also learned about requirements established for TRICARE by the Department of Defense (DoD) and saw an active credentialing application in use by one of BCBSKS’ medical directors. We learned through evaluations and feedback that education regarding BCBSKS’ process of reviewing and completing the credentialing process was valuable. CAQH Updates We heard from participants that providers are being asked to sign and date the CAQH attestation page each time the application is being reattested to. For clarification, the only time the attestation needs to be signed by the provider is on the initial application. For the reattestation, just update any information
on the application and then click the attest button. If there are no changes, just click the attest button to verify the CAQH application is current. Once you reattest, the current date will show in the upper left hand corner of the application.
If you are interested in having a TRICARE/CAQH workshop in your area, or have any questions, please call Linda Pracht at 785-291-7084 or Jennifer Reicherter at 785-291-7516, or e-mail them at [email protected] or [email protected].
Web Changes – Medical Policy Since the publication of Blue Shield Report S-9-11, the following new or revised medical policies have been posted to our Web site at: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.htm
• Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses • Ampyra™ (dalfampridine) Prior Authorization (and Quantity Limit) Criteria • Balloon Sinuplasty for Treatment of Chronic Sinusitis • Biologic Immunomodulators Step Therapy Criteria (through preferred agent Humira®) Progarm Summary • Bone Mineral Density Studies • Botulinum Toxin (BT) • Esophageal pH Monitoring • Foot Care Services • Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer • Gene Expression Assay for Breast Cancer Treatment • Genetic Testing for Congenital Long QT Syndrome • Hyperbaric Oxygen Pressurization (HBO) • Intensity Modulated Radiation Therapy (IMRT) • Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders • Oxycodone Extended Release (ER) Quantity Limit Criteria
December 5, 2011 Blue Shield Report S-11-11 Page 8
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Web Changes – Medical Policy, continued
• Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiogrequency Annuloplasty
• Periodontal Soft Tissue Grafting • Prophylactic Mastectomy • Testing for Vitamin D Deficiency • Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease • Xolair (omalizumab) Prior Authorization Criteria Program Summary
A complete listing of all medical policies can be found on our Web site at: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.htm
Pharmaceuticals
Formulary Update Prime Therapeutics updates the BCBSKS formulary (preferred medication list) on a quarterly basis. Please refer to the link below when prescribing or dispensing medications for your Blue Cross and Blue Shield of Kansas patients. Coverage is subject to the limitations of the member's individual plan.
• http://www.bcbsks.com/CustomerService/PrescriptionDrugs/pdf/2377KS_NatSelectPhysicianFmlryBklt.pdf
A searchable version of the formulary is available at:
• https://www.myprime.com/MyRx/MyPrime/Commercial/findDrugs/KSBCBS/SAMST#ViewFindDrugsEvent Prescription Drug Changes for 2012 Multiple Sclerosis - Interferon Drugs There are four interferon products (Avonex, Betaseron, Extavia and Rebif) used in the treatment of multiple sclerosis (none showing clinical superiority over another). The following formulary and utilization management (UM) changes will occur January 1, 2012.
• FORMULARY: Avonex and Rebif are currently on formulary. Avonex will be removed and replaced with Betaseron. No changes with Extavia (NF) or Rebif (F).
• UTILIZATION MANAGEMENT: Avonex and Extavia are targeted as non-preferred products. Members must try and fail therapy with Betaseron or Rebif, or seek approval through the Prior Authorization process. Existing members on Avonex or Extavia will be grandfathered and not required to change to therapy. The higher copay will apply to Avonex.
The complete criteria and prior authorization (PA) form are available on our Web site, www.bcbsks.com. The PA form also includes a section for sending a prescription order to our preferred specialty pharmacy, Triessent. Hepatitis C Hepatitis C therapy has consisted of the use of one of two interferon drugs, Pegasys or Peg-Intron, in combination with the oral drug ribavirin. Recently two new oral protease inhibitors, Victrelis and Incivek, have been approved for the treatment of chronic hepatitis C. These new drugs will be used in combination with an interferon and ribavirin. Members will have access to either Victrelis or Incivek, but the PA process will ensure that the drugs are used as approved. There are multiple treatment regimens that are dependent on response to the drugs. There are also futility rules for discontinuing the drugs that will be enforced. The following formulary and utilization management (UM) changes will occur January 1, 2012.
December 5, 2011 Blue Shield Report S-11-11 Page 9
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Prescription Drug Changes for 2012, continued
• FORMULARY: Pegasys and Peg-Intron are currently on formulary. Peg-Intron will be removed (non-formulary).
• UTILIZATION MANAGEMENT: Members will be required to try and fail treatment with Pegasys or seek approval through the PA process before being approved for Peg-Intron. Prior authorization is required for both Incivek and Victrelis to manage appropriate treatment in this complex regimen. Existing members on Peg-Intron will be grandfathered and not required to change therapy. The higher copay will apply to Peg-Intron.
The complete criteria and prior authorization (PA) form will be posted when available on our Web site, www.bcbsks.com. The PA form also includes a section for sending a prescription order to our preferred specialty pharmacy, Triessent. Tetracycline Antibiotics The tetracycline antibiotics minocycline and doxycycline are commonly used to treat acne and other infections, including rosacea and periodontal disease. These drugs have been available generically in multiple strengths and in extended release formulations for many years. In recent years, these products have been remarketed in modified dosage forms and strengths with no additional clinical benefit, but with a significantly higher cost.
• Generic doxycycline and minocycline: $6 - $40/Rx • Branded products (Doryx, Oracea, Solodyn): $350 -
$700/Rx
Effective January 1, 2012, brand minocycline or doxycycline drugs will be excluded from coverage. These drugs include the following:
Adoxa, Alodox™, Avidoxy™, Avidoxy™DK, Doryx, Monodox, Morgidox®Kit, Ocudox Kit, Oracea, Oraxyl, Periostat, Vibramycin, Vibra-Tab, Dynacin, Minocin, Minocin Kit, Solodyn
TRICARE®
HIPAA 4010 Cutoff Date Coming Soon All HIPAA-covered entities must be fully compliant with 5010 on January 1, 2012. Medicare, Wisconsin Physicians Service Insurance Corp. (WPS), TriWest Healthcare Alliance, and TRICARE® are in compliance with HIPAA 5010. If you fail to prepare, it will be your business and cash flow that will be affected. If you rely on a vendor or clearinghouse to maintain your billing system, ask them about their plans for transitioning to the new 5010 format. The HIPAA 4010 format cutoff date is December 30, 2011, 4:30 p.m. CST. If you currently receive your 835 Electronic Remittance Advice (ERA) in the X12 835 format, and have not converted to the 5010 format, these files will automatically be converted to the 835 5010A1 format on January 1, 2012.
December 5, 2011 Blue Shield Report S-11-11 Page 10
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
A Closer Look at Balance Billing Balance billing occurs when a provider bills a TRICARE® beneficiary for more than his or her payment responsibility after TRICARE has processed the claim. Both network and participating non-network providers are prohibited from balance billing TRICARE beneficiaries. If you are a network provider, you’ve signed a contract to be paid according to the terms in that contract. Non-network participating providers who accept assignment agree to submit the claim on behalf of the beneficiary and accept the TRICARE-allowable charge as payment in full. Non-network providers who do not accept assignment are also limited in the amount they are able to bill. Non-compliance with this requirement can impact your TRICARE and/or Medicare status. When other health insurance (OHI) is primary and assignment is accepted on the claim, TRICARE will pay the beneficiary liability up to the amount TRICARE would have paid if the beneficiary did not have OHI. If a provider participates with the primary OHI, all OHI rules and requirements must be followed or TRICARE will not pay the claim. These balance billing guidelines are covered in The Code of Federal Regulations (CFR) 32 CFR 199.14 (h) (1) (C), which can be found at http://manuals.tricare.osd.mil/. The billing restriction for non-participating providers is contained in Section 9011 of the Department of Defense Appropriations Act of 1993 (Public Law 102-396). A provider’s standard statement of financial responsibility does not meet the requirements, and is superseded by federal law as stated above. For more information, please refer to the TRICARE Manuals at http://manuals.tricare.osd.mil/ or the Claims/Payments section of http://www.triwest.com/en/provider/claimspayments/ of TriWest.com / Provider. Secure Provider Website Users Can Now Submit Attachments with Claims
Registered users of TriWest Healthcare Alliance’s secure provider website at TriWest.com can include up to three attachments with a new or corrected web-submitted claim. Each attachment can be up to 5 MB in size. It is no longer necessary to submit a paper claim when asked by TriWest to submit an invoice or other documentation with the claim. See example of how easy it is to attach documents to your claims:
http://www.triwest.com/en/provider/claimspayments/claims-submission/Attachment%20to%20Claim%20Submission.pdf
December 5, 2011 Blue Shield Report S-11-11 Page 11
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Emergency Care vs. Urgent Care – It Pays to Know the Difference Emergency rooms (ER) everywhere are experiencing overcrowding, primarily due to visits for conditions that may be better treated by primary care physicians or an urgent care center. The Military Healthcare System is not exempt from this ER crisis. The military community uses ERs at a rate 16 percent higher than the civilian rate (40 percent higher among children; 30 percent higher among women). To help TRICARE® beneficiaries get the appropriate care, reduce the number of unnecessary trips to the emergency room and to help save money for the Department of Defense*, TriWest Healthcare Alliance (TriWest) is asking for your help in educating them on the difference between emergency and urgent care. This can help them save money on out-of-pocket costs and avoid longer waits to obtaining care. TRICARE® defines an emergency as a medical condition that a "prudent layperson" – someone with an average knowledge of health and medicine – believes could threaten life, limb or eyesight without immediate treatment. TRICARE guidelines for emergency care include situations that involve any of the following: Loss of limb Loss of sight Loss of life Severe, persistent pain Health danger to an unborn child At immediate risk of serious harm to self or others as a result of a mental
disorder
Urgent care is considered an illness or injury that won't cause further disability or death if not treated immediately, but needs medical attention to keep it from evolving into a greater threat. Examples of urgent care include: Minor lacerations Urinary tract infections Earaches Migraine headaches Sprains Rising fever
Service members and their families enrolled in TRICARE Prime with a military primary care manager (PCM) should use urgent care facilities through their military clinics first. If that's not an option, they will need to acquire a referral to visit a community urgent care from their PCM or military clinic. Service members and their families can find a local urgent care facility (http://www.triwest.com/OnlineProviderDirectory/UCDirectory.aspx?id=UCDirectory) that accepts TRICARE through TriWest's online provider directory at TriWest.com/ProviderDirectory. Beneficiaries who don't receive an urgent care referral for a community facility may be billed under TRICARE Prime's point-of-service (POS) option. This includes additional cost shares and a deductible. For more information about POS, please refer to the TRICARE Provider Handbook. Additionally, if the beneficiary is an active duty Service member (ADSM), he or she must notify his/her military treatment facility (MTF) of the emergency care incident as soon as possible, regardless of whether or not follow-up care is needed. *According to the Department of Defense, the average cost for an ER visit is over 10 times more than an urgent care or primary care visit.
December 5, 2011 Blue Shield Report S-11-11 Page 12
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Right of First Refusal – Why, How, and Important Points to Remember Like civilian physicians and other providers, military treatment facility (MTF) physicians and providers need to see a variety of patients and diagnoses and perform the full-range of services within their specialty when in medical training and ongoing to maintain proficiency in their specialty. MTF resources (e.g., building, equipment, etc.) also need to be optimized to save taxpayer dollars. This is why MTFs are given the right of first refusal (ROFR) for TRICARE Prime beneficiaries residing in a TRICARE Prime Service Area (PSA) for inpatient admission referrals, specialty appointments, and procedures requiring prior authorization. The MTF staff will review the referral to determine if they have the specialty capability and an available specialty care appointment within TRICARE access standards. If the MTF accepts the care, the beneficiary must obtain these services at the MTF. If the service is not available at the MTF within the appropriate access standards, the beneficiary is referred to a civilian network provider. How the ROFR Process Works
When you determine a referral request is required and submit it to TriWest Healthcare Alliance (TriWest), the request will be forwarded to the MTF to determine if it is able to provide the service. If the MTF can provide the service, TriWest will complete the referral to the MTF and inform the beneficiary to schedule an appointment. If the MTF declines the referral request, TriWest will complete the referral to a civilian network specialist and notify your patient
to schedule an appointment. Prime beneficiaries should have access to a primary care manager whose office is within 30 minutes of home under normal circumstances. Specialty care should be available within one hour of home. Important Points to Remember
An MTF has the right of first refusal for specialty care and other services they can provide for TRICARE Prime beneficiaries living within the 60-minute drive time of the MTF.
Care may be provided by the MTF if the service/care is available, even if you request, or the Prime beneficiary prefers, a civilian specialist.
If the MTF accepts the referral, a TRICARE Prime beneficiary may choose to use his/her point-of-service (POS) benefit and seek care with a civilian provider.
If the MTF accepts the referral, it will call the beneficiary directly to schedule an appointment within the MTF.
The beneficiary should not schedule an appointment with a civilian network specialist until he or she receives approval from TriWest.
Visit TriWest.com/Provider>Referrals/Authorizations for more information on referrals/authorizations.
December 5, 2011 Blue Shield Report S-11-11 Page 13
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
Workshop Opportunities
2012 Provider Workshop Offerings Once again, the professional relations department of BCBSKS will offer educational workshops to review BCBSKS programs, general benefits, current guidelines, proper billing and coding requirements as they apply to BCBSKS, and contact information to address future questions. In addition, two new workshops are being developed to address the topics of ICD-10 and changes to be introduced for 2013. The workshops will provide 3.5 hours of continuing education units (CEUs) pending approval from the American Academy of Professional Coders (AAPC). Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor. You must attend the full session in order to receive your CEUs and your certificate of accreditation. All insurance billing workshops are offered free of charge with snacks provided, compliments of the professional relations department of BCBSKS. Please check the following pages for topics, dates, locations, and times. Online registration will be available after the middle of December on our Web site, www.bcbsks.com/CustomerService/Providers/Training/index.htm; or you may register by phone at the number listed with the workshop you wish to attend. Casual dress is acceptable, but be sure to bring a jacket or sweater since it's often difficult to control the temperature in meeting rooms. Please watch our Web site, www.bcbsks.com, for additional workshops that may be added throughout the year.
2012 PROVIDER WORKSHOPS 9:00 A.M. – 12:30 P.M.
NOTE: Workshops may be canceled if fewer than five people have registered. In the event of
cancellation for any reason, registrants will be notified ahead of time.
January 12 Wichita Insurance Billing Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
February 2 Topeka Insurance Billing Workshop Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
February 9 Wichita Insurance Billing Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
December 5, 2011 Blue Shield Report S-11-11 Page 14
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
February 22 Hays Insurance Billing Workshop Hays Medical Center for Health
Improvement 2500 Canterbury Drive (Park in east parking lot)
785-291-4135, option 5 or 800-432-3587, option 5
February 29 Garden City Insurance Billing Workshop St. Catherine Hospital 401 E Spruce St. Lower Level, Classroom B (Park west of surgery center, enter west door, Outpatient Services)
785-291-4135, option 5 or 800-432-3587, option 5
March 8 Hutchinson Insurance Billing Workshop BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
March 8 Wichita Insurance Billing Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
April 5 Topeka Insurance Billing Workshop Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
April 12 Wichita Insurance Billing Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
April 13 Hutchinson Insurance Billing Workshop BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
April 19 Pittsburg Insurance Billing Workshop Via Christi Hospital 1 Mt. Carmel Way (Sheridan Room)
785-291-4135, option 5 or 800-432-3587, option 5
April 24 Ottawa ICD-10 Workshop Ottawa Family Physicians 1418 S Main, Suite 5
785-291-4135, option 5 or 800-432-3587, option 5
December 5, 2011 Blue Shield Report S-11-11 Page 15
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
May 9 Hutchinson ICD-10 Workshop BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
May 10 Wichita ICD-10 Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
May 24 Emporia Insurance Billing Workshop Newman Regional 1201 W 12th (Continuing Education Room)
785-291-4135, option 5 or 800-432-3587, option 5
June 7 Hutchinson ICD-10 Workshop BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
June 7 Topeka Insurance Billing Workshop Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
June 14 Chanute ICD-10 Workshop Neosho Memorial Hospital 629 S Plummer (The Classroom)
785-291-4135, option 5 or 800-432-3587, option 5
June 14 Wichita ICD-10 Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
June 26 Garden City ICD-10 Workshop St. Catherine Hospital 401 E Spruce St. Lower Level, Classroom B (Park west of surgery center, enter west door, Outpatient Services)
785-291-4135, option 5 or 800-432-3587, option 5
June 27 Hays ICD-10 Workshop Hays Medical Center for Health
Improvement 2500 Canterbury Drive (Park in east parking lot)
785-291-4135, option 5 or 800-432-3587, option 5
December 5, 2011 Blue Shield Report S-11-11 Page 16
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
June 28 Goodland
ICD-10 Workshop Goodland Regional Medical Center 9:00 A.M. – 12:30 P.M. MST 220 W 2nd St. (Large Board Room)
785-291-4135, option 5 or 800-432-3587, option 5
July 12 Wichita ICD-10 Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
July 24 Pittsburg ICD-10 Workshop Via Christi Hospital 1 Mt. Carmel Way (Sheridan Room)
785-291-4135, option 5 or 800-432-3587, option 5
August 9 Wichita ICD-10 Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
August 23 Topeka What’s New in 2013? Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
September 13 Wichita ICD-10 Workshop BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
September 20 Topeka What’s New in 2013? Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
September 25 Ottawa What’s New in 2013? Ottawa Family Physicians 1418 S Main, Suite 5
785-291-4135, option 5 or 800-432-3587, option 5
October 9 Emporia What’s New in 2013? Newman Regional 1201 W 12th (Continuing Education Room)
785-291-4135, option 5 or 800-432-3587, option 5
October 11 Wichita What’s New in 2013? BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
December 5, 2011 Blue Shield Report S-11-11 Page 17
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
October 25 Topeka What’s New in 2013? Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
November 1 Topeka ICD-10 Workshop Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
November 6 Garden City What’s New in 2013? St. Catherine Hospital 401 E Spruce St. Lower Level, Classroom B (Park west of surgery center, enter west door, Outpatient Services)
785-291-4135, option 5 or 800-432-3587, option 5
November 7 Hays What’s New in 2013? Hays Medical Center for Health
Improvement 2500 Canterbury Drive (Park in east parking lot)
785-291-4135, option 5 or 800-432-3587, option 5
November 8 Hutchinson What’s New in 2013? BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
November 8 Wichita What’s New in 2013? BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
November 15 Topeka What’s New in 2013? Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
December 6 Hutchinson What’s New in 2013? BCBSKS First National Bank One North Main St., Suite 301
620-663-1313
December 7 Topeka ICD-10 Workshop Polk School 1234 SW Polk St., Room 101
785-291-4135, option 5 or 800-432-3587, option 5
December 13 Wichita What’s New in 2013? BCBSKS 220 W Douglas Ave., Suite 220 (Conference Room, 2nd Floor)
316-269-1674 or 800-432-0216, ext. 1674
December 5, 2011 Blue Shield Report S-11-11 Page 18
Current Procedural Terminology 2010 American Medical Association. All Rights Reserved. Note: Codes published herein are current on the publication/effective date and are subject to change.
Sent To: CAP except Dentists and Pharmacies Contains Public Information
May Joy light your Holidays!