1. An Independent Licensee of the Blue Cross and Blue Shield Association. 2010 All Payers Dec 17, 2010

2. 2 Presenters Cindy Garrison, CPC Denny Hartman, CPC Marie Burdiek Vicki Haverkamp

3. 3 Agenda Medical Policies National Consumer Cost Tool TRICARE Cindy Garrison Staff changes Misc Updates Denny Hartman Healthcare Reform State of Kansas 2011 Changes FEP 2011 Changes Marie Burdiek HIPAA Electronic Claims Electronic RA

4. 4 Institutional Relations Staff Changes Angie Strecker, DirectorTeresa VanBecelaere, Manger Christie Blenden, Provider/Contract Consultant

5. 5 Misc Updates Health Information Technology (HIT) UB-04 (FL70) Limited Patient Waiver Medical Records Request Medical Policy Router Precerts

6. 6 Misc Updates - Health Information Technology (HIT) New Web page

7. 7 Enter the appropriate diagnosis code describing the patient's reason for the visit at the time of the outpatient encounter. Misc Updates – UB-04 – Patient Reason for Visit Effective Jan 1, 2012  Required for ALL outpatient claims Claim submission  Electronic – loop "2300 HI"  Paper – form locator 70 Be sure your vendors are aware  Start working with them NOW 70 PATIENT REASON DX aBc

8. 8 Misc Updates – Limited Patient Waiver New waiver Limited Patient Waiver (LPW) Notice of Personal Financial Obligation (NOPFO)  Discontinue effective Jan 1, 2012 Available on the Web at http://www.bcbsks.com/CustomerService/Providers/f orms.htm http://www.bcbsks.com/CustomerService/Providers/f orms.htm

9. 9 Misc Updates – Medical Records Request Facility responsible for obtaining records  Hospital's  Physician's Will only ask for records once If you question the processing, you can  Call customer service  Do a written inquiry within 120 days of RA  Do a written appeal within 180 days of RA

10. 10 Misc Updates – Medical Policy Router Gives providers the ability to self-service Eliminate some phone calls Increase transparency Potentially prevent some claim issues or claim denials due to medical policy

11. 11 New Medical Policy Web Page Enter out-of-area three-digit alpha prefix Effective Oct 1, 2010

12. 12 Misc Updates – Pre-Certification When Required Pre-certifications in Process Discharged

13. 13 Denny Hartman, CPC Provider Consultant

14. 14 Health Care Reform Check out the BCBSKS Web site – www.bcbsks.com  FAQs are available on our Web site regarding "Dependent to Age 26" and "Grandfathered Plans," as well as other topics.  Details about continuing legislative health care changes and their affect on coverage. Sign up to receive Health Care Reform Updates via e-mail.

15. 15 Health Care Reform Patient Protection and Affordable Care Act (PPACA)  Blue Cross Newsletter, Nov 19, 2010 (BC-10-16)  Website for a complete listing of preventive services:  www.healthcare.gov/law/about/provisions/services/lists.htmlwww.healthcare.gov/law/about/provisions/services/lists.html Preventive Health Benefits

16. 16 Health Care Reform Grandfathered Health Plans  PPACA does not require 100% of preventive benefits, however, must comply with some of the requirements Non-grandfathered Health Plans  Health plans must provide PPACA's recommended Preventive Health services without cost share to the insured  All deductibles, coinsurance or co-payments are waived and the health plan is to pay 100% of the plan allowance to the BCBSKS contracting provider Health Plans

17. 17 Health Care Reform Can be outpatient setting Use CPT description of preventive services when choosing CPT code Annual exam for members 3 years and older allowed per benefit period with no cost sharing Annual Wellness / Preventive Services

18. 18 Health Care Reform Diagnosis code is very important! Quick reference guide on bcbsks.com (newsletter) If not Well Person ICD-9 codes, then it is cost shared! Diagnosis codes drive cost sharing and in some cases, actual coverage! Coding for Preventive Health Benefits

19. 19 State of Kansas 2011 Changes Patient Protection and Affordable Care Act (PPACA) Non-grandfathered – Will not be exempt from PPACA's provisions Preventive care provided Coverage for children up to age 26 SOK offers PSA's, unlimited mammograms, and colonoscopies regardless of diagnosis as long as member uses contracting provider

20. 20 State of Kansas 2011 Changes Must be pre-approved May include Applied Behavioral Therapy, Development Speech Therapy, Development Occupational Therapy Developmental Physical Therapy Periodic re-evaluations and assessments required Continued improvement must be shown Call New Directions for prior approval Autism Services

21. 21 State of Kansas 2011 Changes Intravenous & Injectable Anti-cancer Drug Rider  Separate coinsurance and coinsurance maximum  Medical deductible & coinsurance does not apply  25% coinsurance to maximum of $750 per member / per year  After $750 max is met, coverage is 100% rest of year  Non-network provider – Same benefits and member pays amount over the MAP

22. 22 State of Kansas 2011 Changes General Information  Return requested information within one (1) year and 90 days from the date of service. If request is close to the end of this time period, you have 90 days from date request for more information is made. If not received within 90 days, claim will be denied.  Adjustments of claims – Requests must be received within one 1) year and 90 days from the date of service. After 1 year and 90 days from date service, only claims that require adjustments due to legal finding or audit will be adjusted if the request is received within 180 days of the completion of that finding. Fraudulent billing has no time limits.

23. 23 State of Kansas 2011 Changes Blood, Blood Products, Blood Storage Surgical treatment or other related services for surgical treatment of obesity Sleep studies provided within the home Supplies and prescription products for tobacco cessation programs and treatment of nicotine addiction. Exclusions (not a complete list):

24. 24 State of Kansas 2011 Changes Covers the Medicare Part A & B deductible and coinsurance The 1st three pints of blood are covered Hospice care is available effective January 1, 2011. There is no coverage for charges in excess of Medicare's approved amounts Skilled nursing – The Member must meet Medicare's requirements Kansas Senior Choice Plan C Summary

25. 25 Federal Employee Program 2011 Changes Non-grandfathered under Patient Protection and Affordable Care Act (PPACA) Preventive care with no cost sharing for members when performed by a Preferred Provider Coverage for children up to age 26 Basic or Standard Option

26. 26 Federal Employee Program 2011 Changes Uses CAP Blue Cross contracting provider contract as provider network ID cards use:  104 = Standard Option / Single  105 = Standard Option / Family Standard Option

27. 27 Federal Employee Program 2011 Changes Uses the Blue Choice provider network except for emergency care NO BENEFITS are available for service provided by institutional providers who are not part of Blue Choice provider network Non-hospital institutional providers who are in the CAP provider network are considered to be Blue Choice providers ID cards will have the work "BASIC" written on outline of the United States and the following:  111 = Basic Option / Single  112 = Basic Option / Family Basic Option

28. 28 Federal Employee Program 2011 Changes Prior approval required for out-patient surgery for morbid obesity Prior approval required for all out-patient IMRT services except IMRT related to the treatment of head, neck, breast or prostate cancer. Prior approval is required for IMRT of brain cancer Pre-certification is required for partial day, home health, hospice, in-patient skilled nursing facilities and in- patient services Miscellaneous

29. 29 Marie Burdiek EDI Account Representative

30. 30 HIPAA 5010 What is HIPAA 5010? Are you Ready?

31. 31 HIPAA History Current version is 4010A1 New version is 5010 5010 applies to all electronic healthcare transactions Health Insurance Portability and Accountability Act requires certain standards for electronic healthcare transactions.

32. 32 Covered Entity All covered entities who exchange information electronically must do so in the HIPAA 5010 format. Covered entities include:  Health Plans/Payers  Health Care Clearinghouses  Health Care Providers – any provider of medical or other health services, or supplies, who transmits health information electronically

33. 33 Industry Timelines December 31, 2010 January 1, 2011 January 1, 2012  What happens Jan. 1, 2012 ?  Only version HIPAA 5010 will be accepted  Industry is not expecting any extensions to these dates

34. 34 Enhancements with 5010 Improvements are made in technical, structural and data content It is more specific in what data needs to be collected and transmitted Accommodates reporting of clinical data (e.g., ICD-10 diagnosis and procedure codes effective October 1, 2013) Distinguishes the difference between a principal, and admitting diagnosis codes Increases the number of diagnosis codes that can be reported

35. 35 Examples of Changes Billing and service facility ZIP codes are now expanded to the ZIP + 4 Billing provider segments must contain the physical address not a P.O. Box The 835 transaction will only return the first 20 characters of the patient account number Preferred Health Professionals (PHP) Payer ID 00023 will be replaced by 31478

36. 36 Claims Acknowledgement and Reporting Changes Reporting will change with 5010 999 will replace the 997 277CA (Claim Acknowledgement)

37. 37 5010 Enrollment Procedures Active Trading Partners will not have to complete enrollment forms for 5010. Vendors will determine test or production status. PC-ACE Pro32 users will not have to test. EDI will rely on email as the primary means to contact trading partners regarding 5010 setup.

38. 38 HIPAA 5010 – ASK Timelines

39. 39 Changing to ICD-10 US Standard on 10/01/2013 No phase in period ICD-10 is date driven by date of service  ICD-9 will continue until all services prior to 10/01/2013 are through the system.  ICD-10 is the only coding valid on claims with date of service 10/01/2013 www.cms.gov/ICD10

40. 40 How big is this change?

41. 41 HIPAA 5010 Sets the Stage for ICD-10 ICD-10 cannot be implemented until the transition to 5010 is complete! Extension was previously granted. No additional extensions.

42. 42 Questions to Ask Your Vendor, Billing Service or Clearinghouse 1.Will software upgrades or changes accommodate both HIPAA 5010 and ICD-10? 2.What if any costs are involved? 3.When will the upgrades or changes be available for implementation? 4.Will I be required to test with ASK? 5.Will my software support and convert the 277CA into a readable format? 6.What customer support and training is provided? 7.How will the software changes handle both ICD-9 and ICD- 10 before and after the deadline for code sets?

43. 43 HIPAA 5010 - Next Steps  What should I do? Contact vendor  Ask for dates of activities, upgrade deployment and transitions Contact clearinghouse  Ask if they have been in touch with your payers  Ask for dates for activities and transitions Self educate  Frequently review payer Web sites for HIPAA 5010 information.  Sign up for e-mail notification.

44. 44 TURN OFF PAPER REMIT

45. 45 TURN OFF PAPER REMIT

46. 46 BCBSKS Internet Log In Issues  Contact BCBSKS Customer Service  1-800-432-3990 Please have user name NPI number Answers to your challenge questions

47. 47 Vicki Haverkamp, Queen Provider Consultant

48. 48 BCBSKS Secondary to Medicare (MSP) While our expectation is to receive secondary claims to Medicare via the cross over system, this does not always happen.

49. 49 MSP Some of the reasons the claim does not cross over could be: oWe do not have the patient loaded as Medicare primary oWe have the wrong Medicare information loaded (i.e. ID, name, effective date, etc.) oThird-party claims oNegative amounts

50. 50 MSP Providers should contact customer service (1-800-432-3990) or their provider consultant if the Medicare remittance advice indicates the claim did not crossover to BCBSKS (no MA18) for help in determining why a claim was not received. Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them MA18

51. 51 MSP – Electronic Claim Submit all the Medicare processing information. Total amount billed Medicare payment Provider Write-off Deductible & coinsurance Non covered amounts when applicable Call ASK at 1-800-472-6481

52. 52 National Consumer Cost Tool New effective Jan. 1, 2011 The purpose is to enable members to obtain information on estimated costs for common health care services. Not available to BCBSKS members at this time.

53. 53 NCCT Members will access through their Plan's Web site. The member will enter their member Identification number, Select the treatment category, and Select the geographic area desired for service. Members can choose from 54 of the most common, elective procedures for inpatient, outpatient and diagnostic services. How it works

54. 54 NCCT The estimates are developed using twelve months of claims data from contracting facilities. Medicare and secondary claims are excluded. For the inpatient treatment,  categories episodes are built by summing all claims created at the facility from admission to discharge. Outpatient episodes  sum all claims created on that day of service at that facility and also may include ‘pre-work’ diagnostics done beforehand. Cost estimates are updated approximately every six months. Pricing

55. 55 NCCT The approximate costs for the selected treatment category, for hospital/facility-based services, the approximate costs with the name and practice location of the hospital/facility, the approximate out of pocket liability calculated by the member’s Plan, and links to supplemental information such as health/wellness, care management, quality, etc. Information Exhibited

56. 56 Off Site Services Services provided off-site of the physical presence of the main hospital campus must be billed on the CMS-1500 claim form, except in those cases where that off-site location is the sole place of service for an outpatient ancillary service or as determined by BCBSKS. When hospitals provide multiple services off-site of the main hospital campus, an addendum agreement to peer group pricing may be offered.

57. 57 Off Site Services (cont) Submit on a CMS 1500 Reimbursement will be based on  the Blue Shield fee schedules and  Blue Shield guidelines will be applicable.

58. 58 Policy and Procedure 2011 Update Letter July 26, 2010 Minor Changes