1. BlueCross BlueShield of Western New York Chiropractic Program
Welcome Everyone to the First Chiropractic Workshop
Proprietary & Confidential//Overview for Educational Purposes//Additional Questions//Contact Provider Relations 1

2. Chiropractic Workshop Agenda
Chiropractic Program
Provider Relations
HEALTHeNET/ ASK/ Provider Website
Quality Management
Wellness Benefit
Health Care Services
Future Projects
Questions

3. Changing Environment
The consumer’s role in health care decision making is expanding
Consumers will have more options for how, where, and from whom they purchase health insurance
Costs continue to rise and the quality of care needs to improve
Government regulations are dramatically changing

4. Beginning January 1, 2013 Chiropractic Program
PATIENT CENTRIC MODEL WHAT AREAS WILL THIS NEW MODEL TOUCH?
NEW PERSPECTIVE REGARDING CHIROPRACTIC CARE
WE HOPE TO INCORPORATE SOME OUR EXISTING PROGRAMS AND WELL AS CREATE SOME NEW PROGRAMS
SOME SERVICES THAT YOU MIGHT NOT KNOW ABOUT
WE PROVIDE SERVICES LIKE
HEALTH PROMOTIONS
HEALTH COACHING
DISEASE MANAGEMENT
CASE MANAGEMENT
DISCOUNTED SERVICES
FREE WELLNESS SEMINARS/PRESENTATIONS

5. Chiropractic Program Goals
Leverage claims data and quality measures to substantiate chiropractic services
Decrease spinal surgeries
Reduce pharmaceutical dependence
Pain medications and spinal injections
Inappropriate and unnecessary imaging for spinal issues
Optimize chiropractic provider network performance
Reduce administrative burden; less paperwork
More time with patients
Reduce over- and under-utilization
Increase outcomes and reduce risk
Align patients and providers
Support performance management programs

6. Chiropractic Advisory Committee
WHY DO WE NEED A CHIROPRACTIC COMMITTEE?
WE DECIDED TO REACH OUT TO PARTICIPATING PROVIDERS IN OUR NETWORK AND FOSTER A DIRECT RELATIONSHIP
WHEN THERE IS DIALOGE WITH THE PROVIDERS, MEMBERS, AND HEALTH INSURANCE MORE CAN BE ACCOMPLISHED
A COLLABORATION LIKE THIS CAN POTENTIALLY CHANGE PERCEPTIONS REGARDING CHIROPRACTIC AND HEALTH INSURANCE COMPANIES
WITH SUCH A NEW PROGRAM IT TAKES A TEAM WHICH IS SO EXCITING!!!! 6

7. Chiropractic Advisory Committee
Ensure continuing access to high-quality, medically appropriate, evidence-based, cost-effective chiropractic care.
Maintaining a consistent and clinically appropriate approach in the administration of chiropractic care, including development of its clinical practice guidelines.
Develop clinically integrated programs and quality incentive programs.
Aid in the development of coverage criteria, review of coverage decisions, and technology assessments.
Review administrative rules pertaining to health care issues that may be related to the delivery of high-quality chiropractic care.
SO WHAT ARE OUR GOALS,
INTERNAL REPRESENTATION
EXTERNAL REPRESENTATION
MOVE THE CHIROPRACTIC COMMUNITY THROUGH DIRECT INSURANCE COMMUNICATION

8. Chiropractic Advisory Committee
Clinical practice guidelines
Chiropractic Treatment Request Form
Policies and procedures
Medical procedures
Outcome-based pilot programs
Health Care Services programs

9. Chiropractic Committee Commitment
Members are appointed by BlueCross BlueShield for a two-year term beginning with attendance at their first committee meeting and may be renewed for two additional two-year terms.
However, to ensure institutional memory of the committee, initial appointments may be extended to three- or four-year initial appointments.
After the initial two years of the committee’s existence, one-third of the members will rotate off the committee after two years, one-third after three years and one-third after four years.
If members do not volunteer to rotate off the committee, selection will occur via a random name selection process.

10. Provider Relations
ENHANCED RELATIONSHIP WITH OUR BCBS CHIROPRACTIC PROVIDERS 10

11. Provider Relations
The Provider Relations Specialist is your primary link with BlueCross BlueShield.
Delegated by zip code or territory
Share information and analyze practice patterns in an effort to help you provide quality, cost-effective care
Our commitment to partnering with our participating providers is vital to providing quality coverage for our members.

12. Medical Management Model
Members will have unlimited chiropractic coverage.
Members and providers will no longer have to complete the paperwork; therefore, access to care is easier with our model.
A limited number of BlueCross BlueShield ASO contracts will still be managed through the preauthorization process.
Chiropractors will now have a direct line of communication with the health plan, as well as the ability to share recommendations on quality programs and other initiatives.

13. Network Updates
Management of Services for chiropractors, massage therapists, and acupuncturists.
Open network enrollment for Erie County, NY:
January 1, 2013
Previously, participating chiropractic providers:
Were dual contracted with the Palladian network and the BlueCross BlueShield network.
Will not need to do anything because your participating provider agreement with BlueCross BlueShield will automatically become effective on January 1, 2013.
To date, we have not received a single notice of termination from a chiropractor
Therefore, the network and the access to care is not reduced
"the change in administration of the benefit will also affect management of services.... as well as massage therapist and acupuncturists..."
new graduates are welcome to join the network.

14. Claim Submission Dates of service December 31, 2012 and prior
continue to submit to Palladian Health.
Dates of service January 1, 2013 and later
submit to BlueCross BlueShield for processing and reimbursement
Payor ID: 00801

15. BlueCross BlueShield Reimbursement and Fee Schedule
Increase in BlueCross BlueShield fee schedule for initial and established office visits by 5 percent starting January 1, 2013
All lines of business
Re-evaluation fee has been included
Fee schedule is available on the provider website
"A recent internal policy change.....dramatically reduce the reimbursement..."
Fees are not going down.
Our reimbursement will increase 5% as of 1/1/13 for all lines of business.
When Palladian learned of the termination of the contract, they instituted a 30% increase across a subset of business for the chiropractors, in an attempt to gain their support.
Their perception will be that we are now taking them "two steps back" with the 5% increase.
Keep in mind that the 30% increase was only for our Managed Care lines of business: relatively small compared to the rest.

16. Provider Credentialing Process (CAQH)
Providers can enroll into our health plan by filling out the Universal Credentialing Application with Council for Affordable Quality Healthcare (CAQH).
Enter your CAQH Provider ID to enter or update your information
Authorize BlueCross BlueShield to access your information electronically

17. Direct Communication Provider Representatives Provider Website
Provider Quarterly Newsletters
Yearly Provider Expo
Provider Customer Services
Chiropractic Advisory Committee

18. Quality Management
INTERNALLY TREATED LIKE ANY OTHER PROVIDER 18

19. Quality Management Health Insurance Overview InterQual Criteria
Chiropractic Authorization
Chiropractic Treatment Request Form/Flow Chart
Internal Processes
Quality Department
TREATED THE SAME AS ALL OTHER PROVIDERS

20. Health Care Plans and Systems
Managed Care Plans
Preferred Provider Organization (PPO)
Participants care must be provided by selected health care providers, but participants can go outside the network; co-insurance, high deductibles.
Exclusive Provider Organization (EPO)
Participants care must be provided by selected health care providers, but participants cannot go outside the network; they are completely responsible for payment.
Health Maintenance Organization (HMO)
Health care system assumes both the financial risk associated with providing services and responsible for health care delivery in a particular geographic area; usually a fixed, pre-paid fee.
Point-of-Service (POS)
HMO/PPO ‘hybrid’: resembles HMO for in-network services but services outside of the network are usually reimbursed in a manner similar to fee schedule.
Self-Insured Plans
Administrative Services Only (ASO)
Employer hires a third party to deliver administrative services; claims processing and billing; employer bears the risk for claims.

21. Members Requiring Authorizations
ASO/Experience Rated Groups (Self-Funded)
Fastest-growing types of employee benefit arrangements
Employers are responsible for directly funding all claims that their employees incur
Employers pay a fixed fee for administrative services such as claim payment and management reporting
An insurance company provides those administrative services, but doesn’t collect any premiums where no insurance risk has been underwritten
Benefits:
More time with your patients/family/friends
Improved quality of life

22. Chiropractic Visit Restrictions
Three Major Limitations:
Medical necessity prior authorization requirement
Can vary from first visit to the twentieth visit
Maximum dollar limit, ex: $200
Maximum visit limit, ex: 20

23. Clinical Practice Guidelines
InterQual Chiropractic Criteria
Created by actively practicing chiropractors across the country
Promotes evidence-based standards of care
Accepted by:
Chiropractic Advisory Committee
Quality Management Committee
Available on the Provider Website

24. Medical Review: Chiropractic Treatment Request (CTR)
Provider Office
Checks patient contractual agreement
If no limits: treat patient
If limits: determine allowable visits
Complete the CTR form before contractual visits have been exhausted
For example:
If five visits are allowed without medical necessity, complete CTR form after the fourth visit
Fax completed form BlueCross BlueShield at
Provider and member will be notified of decision within three days via:
mail
phone call
If additional visits are required, submit additional CTR forms
THE FORM IS SUBMITTED VIA FAX
THE FORMS WILL GO TO OUR UTILIZATION MANAGEMENT DEPARTMENT FOR REVIEW
IT IS SUBMITTED
CHECKED IF NECESSARY AND COMPLETE
SUBMITTED TO A RN FOR REVIEW AND THEN TO A CHIROPRACTOR

25. Page 1
WILL BE AUTOMATED IN THE FUTURE WHICH IS WHY IT IS FIXED BLOCKS/BUBBLES

26. Page 2

27. Chiropractic Treatment Request
Step 1:
Checked by staff:
Eligible member
If required
Complete
Step 2:
Checked by RN:
CTR reviewed against InterQual Criteria
Additional visits given
If unable to make a determination
Step 3:
Checked by Chiropractor:
Combination of InterQual Criteria and clinical judgment

28. 2ND RUN THROUGH:
VISITS WILL NOT EXPIRE
IF 8 VISITS ARE ALLOTTED AND NOT USED FOR MONTHS, THE PROVIDER MUST REMEMBER TO COMPLETE ANOTHER FORM BEFORE VISITS HAVE BEEN EXHAUSTED OR THE CLAIM WILL DENY BECAUSE OF LACK OF AUTHORIZATION

29. Provider Expectations
Self Governance
Maintain quality medical records
Comply with HIPAA standards
Practice Guidelines
Apply appropriate evidence-based care to members
Ensure BlueCross BlueShield-accepted clinical guidelines are used
Comply with regulatory agencies
Yearly Evaluation of the Chiropractic Program to Access Progress

30. Wellness Benefit
The <BlueCross BlueShield><BlueShield> healthy changes everything® wellness card has arrived!
The new wellness benefit helps members to live a healthier lifestyle with an annual allowance for services such as:
Fitness centers
Massage therapy
Health food stores
Acupuncture treatments
Chiropractic visits
And, much more!
The Wellness card comes with a nationwide network of retailers. Members have access to providers based on merchant type and/ or merchant category.
If member has trouble using card at a particular facility, please have a member of the sales team contact Krista Lennox
All transactions are handled through Visa and processed through our vendor, Discovery Benefits.
Member questions and card issues will be handled directly by Discovery Benefits; customer service number is located on the back of the wellness card.
Members are required to activate card prior to use, the phone number to activate will be provided with the card.
How it works:
Once the card is activated it can be used to pay for services at approved health and wellness retailers throughout the country.
The retailer will accept the payment and it will be deducted from members account.
If the entire allowance used, member will pay for any continued services until the balance is reset for your next plan year.
Any internal sales and account team questions can be directed to Krista Lennox, Health Promotions Program Administrator
Current1/1/13Aqua, with Aqua cardAqua, with $250 Wellness Card (regardless of family size) Lifestyle BenefitWellness Benefit with Wellness Card (available in increments of $50, ranging between $50-$600. Healthy Balance Does not have debit card$250 Wellness Card
I have contracted with nearly 100% of the massage therapists and acupuncture practitioners that are currently in the Palladian network.
There were 20 acupuncture providers recruited and we received 18 signed contracts back. The other 2 individuals could not be located.
There were 218 massage therapists recruited. We received 210 signed contract back. The other 8 individuals could not be located.
Keep in mind that the contracting only supports members who have benefits within their medical product. We did not contract for discounts.
I am not certain what benefit design these groups have; therefore, I will need Laurie to help with a response about the massage and acupuncture services. I will tell you what I can. 30

31. The Wellness Card
Available with the Aqua plan, Wellness Benefit (formerly Lifestyle Rider), and Healthy Balance, effective January 1, 2013.
All subscribers, will receive a Visa to be used with a nationwide network of health and wellness retailers based on merchant type and/or merchant category.
Fitness centers
Massage therapy
Chiropractic visits
Health food stores
And many more!
All transactions are handled through Visa and processed through our vendor, Discovery Benefits.
The <BlueCross BlueShield><BlueShield> healthy changes everything® wellness card has arrived!
The new wellness benefit helps members to live a healthier lifestyle with an annual allowance for services such as:
All transactions are handled through Visa and processed through our vendor, Discovery Benefits.
Member questions and card issues will be handled directly by Discovery Benefits; customer service number is located on the back of the wellness card.
Members are required to activate card prior to use, the phone number to activate will be provided with the card.
Current1/1/13Aqua, with Aqua cardAqua, with $250 Wellness Card (regardless of family size) Lifestyle BenefitWellness Benefit with Wellness Card (available in increments of $50, ranging between $50-$600. Healthy Balance Does not have debit card$250 Wellness Card

32. The Wellness Card
Lifestyle Rider: Effective January 1, 2013 the Lifestyle Benefit will be referred to as the Wellness Benefit.
A wellness card will be provided to subscribers of the Aqua plan, Wellness benefit and Healthy Balance.
How it works:
Once the card is activated it can be used to pay for services at approved health and wellness retailers throughout the country.
The retailer will accept the payment and it will be deducted from members account.
If the entire allowance used, member will pay for any continued services until the balance is reset for your next plan year.
Any internal sales and account team questions can be directed to Krista Lennox, Health Promotions Program Administrator
Current1/1/13Aqua, with Aqua cardAqua, with $250 Wellness Card (regardless of family size) Lifestyle BenefitWellness Benefit with Wellness Card (available in increments of $50, ranging between $50-$600. Healthy Balance Does not have debit card$250 Wellness Card

33. Senior Fitness Benefit
The BlueCross BlueShield network will be partnering with SilverSneakers, effective January 1, 2013.
If you are not currently part of the SilverSneakers network but would like to be, you can submit a request to begin the application process online at silversneakers.com.
If you are already a SilverSneakers provider, no further action is required.
YOUR CAN BECOME A SILVER SNEAKER PROVIDER JUST GO TO THEIR WEBSITE

34. HEALTHeNET Web Application
PCI HELP DESK HOURS OF OPERATION: 7 a.m. - 7 p.m. Monday-Friday

35. Administrative Transactions: One-stop Shopping…
EPRO
Provider File Updates
Future???
HIPAA
Claims Status
Transaction
Referrals
Security:
One User ID
& Password
Membership
& Eligibility
HEALTHeNET
30,000+ users
Claims Adjustment Requests

36. Log In
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37. Disclaimer
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38. Home Page
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39. Eligibility and Benefits
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42. Eligibility Details (Plan Benefits)
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43. Eligibility Detail (General Benefits)
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44. Claim Status Request
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45. Claim Status Request – New Functionality

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49. Provider Inquiry Transaction

50. Provider Inquiry Summary Transaction

51. Available Inquiry Summaries

52. Provider Inquiry Summary Detail

53. Provider Website bcbswny.com

54. Provider Website

55. Network Information

56. Help Me Find

57. News & Events

58. Resources

59. Policies

60. Payment and Operations

61. Health Care Services 61

62. Health Care Services Member/Provider Experience Personalized programs
Targeted Interventions
YOU ALREADY ACT LIKE A PCP
Diverse Communication

63. Managing the Spectrum of Care
Intervention
Health Coaching
Disease Management
Case Management
Objectives
Lifestyle management
Wellness-focused
Clinical Coaching
Physician Involvement
High cost
Catastrophic illness
Frequent ER/Hospitalization
Method
Motivational interviewing
Skill building
Holistic approach
Education/resources
Changing behaviors
Using latest guidelines
Obtain medically necessary care and support
Member-focused care plan
Programs
Fitness
Nutrition
Stress management
Smoking cessation
Weight management
Asthma
Cardiac
COPD
CHF
Diabetes
ADHD
Depression
Back care
Synergy DM
Obstructive Sleep Apnea
General
Maternal-child
Transplant
Chronic kidney
Palliative care
ER use/high cost
Rare conditions 63 63

64. Advanced Care Coordination
Outreach
On-site
Community
Health coaching
Case management
Disease management
Behavioral health
Health advocate
Tailored clinical mailings
Online consultation
Health promotion
support and consultation
On-site clinical support
[CM, DM]
On site workshops
Interactive programs
Flu shot clinics
Biometric assessments
Community wellness
program
Childhood wellness
initiatives
Home care collaboration
VNA
Community
sponsorship opportunities
Member

65. Future Projects 65

66. Future Projects Educational workshops
Chiropractic continuing education
Pay for performance pilots
Interdisciplinary and chiropractic care connections
Patient-centered medical home
College collaborations

67. Overview What are the benefits?
Member
Unrestricted chiropractic care*
Control over their health decisions
Improved outcomes
Improved overall satisfaction
Improved health and well-being
Reduction in member health care costs
Chiropractic
Increase reimbursement
Eliminates paperwork
Reduces administrative burden placed on the provider, staff, and patient
Allows additional time to treat patients
Improving satisfaction and outcomes for patient
Internal direct contact with BlueCross BlueShield
Community
Musculoskeletal-specific wellness seminars
Collaborate with providers/members to drive performance/quality
Improving customer satisfaction: providers, members, employers, community
*Please refer to members contractual agreements for chiropractic coverage 67

68. We look forward to a long, exciting future. Questions?
Please contact: BlueCross BlueShield of Western New York
Provider Relations Department
BlueCross BlueShield of Western New York is a division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. BlueCross, BlueShield and the Cross and Shield symbols are registered trademarks of the BlueCross BlueShield Association. WNY_2477_11-10