2010 All Payers

1. 2010 All Payers Dec 17, 2010

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

3. Agenda

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

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

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

7. 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 Enter the appropriate diagnosis code describing the patient's reason for the visit at the time of the outpatient encounter.

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/forms.htm

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

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

13. Denny Hartman, CPC Provider Consultant

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. Health Care Reform Preventive Health Benefits • 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.html

16. Health Care Reform Health Plans • 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

17. Health Care Reform Annual Wellness / Preventive Services • 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

18. Health Care Reform Coding for Preventive Health Benefits • 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!

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. State of Kansas 2011 Changes Autism Services • 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

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. 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. State of Kansas 2011 Changes Exclusions (not a complete list): • 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.

24. State of Kansas 2011 Changes Kansas Senior Choice Plan C Summary • 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

25. Federal Employee Program2011 Changes Basic or Standard Option • 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

26. Federal Employee Program2011 Changes Standard Option • Uses CAP Blue Cross contracting provider contract as provider network • ID cards use: • 104 = Standard Option / Single • 105 = Standard Option / Family

27. Federal Employee Program2011 Changes Basic Option • 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

28. Federal Employee Program2011 Changes Miscellaneous • 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

29. Marie Burdiek EDI Account Representative

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

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

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

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. HIPAA 5010 – ASK Timelines

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. How big is this change?

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

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. TURN OFF PAPER REMIT

45. TURN OFF PAPER REMIT

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. Vicki Haverkamp, Queen Provider Consultant

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

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. MA18 Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them