Inside This Issue: BCBSKS Claims Secondary to Medicare

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1 January 24, 2011 S-1-11 The Blue Shield Report is published by the professional relations department of Blue Cross and Blue Shield of Kansas. OUR WEB ADDRESS: Ann Dunn Communications Coordinator Questions: Contact your professional relations representative or the professional relations hotline in Topeka at or 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: Reminders BCBSKS Claims Secondary to Medicare... Page 1 Policy Change Requiring Referring Provider Name/NPI on Claim... Page 2 Updates Administration & Immunization Reimbursement... Page 3 Authenticating a Provider... Page 3 Autism Rider for SOK Pilot Benefit... Page 4 Diagnosis Code V Page 8 Modifier 33 Preventive Service... Page 8 Workshop Opportunities Workshop Change... Page 8 Reminders BCBSKS Claims Secondary to Medicare This article was published to the Web site under "Latest News" dated January 7, A new year is here and with a new year comes new Medicare deductibles. The new deductibles are applied to claims with dates of service January 1 and after. This can create problems for those expecting Medicare primary claims to auto crossover to Blue Cross and Blue Shield of Kansas (BCBSKS) and be paid automatically. Crossover issues have, for the most part, gone away. BCBSKS periodically experiences issues with certain claims that have been processed by Medicare. These issues include the following: Third party payer on the claim Medicare is now the primary payer and is not loaded to BCBSKS system The Medicare information loaded to BCBSKS system is incorrect A negative Medicare paid amount is present on the claim

2 January 24, 2011 Blue Shield Report S-1-11 Page 2 BCBSKS Claims Secondary to Medicare, continued Historically, higher than normal volumes of these claims issues present themselves during the first quarter of each year. With the implementation of HIPAA version 5010, January 1, 2012, these issues are anticipated to be resolved. If you experience BCBSKS secondary to Medicare claim problems, please contact BCBSKS Customer Service Center for assistance in researching why the claim did not automatically cross over from Medicare. If your BCBSKS Secondary to Medicare claim did not automatically cross over, please submit the claim electronically 15 days after the Medicare adjudication date. Include all Medicare processing information found on the remittance advice such as: The total amount billed Medicare paid amount Medicare contractual write-off Coinsurance Deductibles Non-covered portion (if applicable) Without all the pertinent information BCBSKS cannot "balance" the claim and assure that correct reimbursement is made. If BCBSKS cannot "balance" the claim, you will receive a letter requesting that you resubmit a paper claim with a copy of the Medicare RA to insure proper processing of the claim. This only delays processing and adds additional costs to your office and ours as well. Filing a paper claim including RA should be the last resort. If you are having difficulties submitting secondary claims successfully to BCBSKS, please contact the EDI Help They will work with you so that you can submit your claims electronically. Policy Change Requiring Referring Provider Name/NPI on Claim We would like to take this opportunity to offer a friendly reminder of the 2011 change in Policy Memo No. 1, Section XV. "Claims Filing," which requires contracting providers to submit claims using their National Provider Identifier (NPI). As stated, "the name of the ordering provider, when applicable, (including NPI or specific performing provider number, except when exempt by law) must appear on every claim." This information appears on page 12 of Policy Memo No. 1, and may be accessed by clicking on the following link: sional/policymemos/pdf/2011_bcbsks_cap_policymemo_01.pdf For electronic claims the Referring Provider information must be submitted in the 2310A loop, the Ordering Physician information must be submitted in the 2420E loop, and the Supervising Provider information must be submitted in the 2310E loop. The name of the referring physician, ordering, or supervising provider should appear in box 17 of the paper claim form, with the NPI number of that provider listed in box 17b.

3 January 24, 2011 Blue Shield Report S-1-11 Page 3 Updates Administration & Immunization Reimbursement With replacement of CPT immunization administration codes for 2011, the following will provide instruction on billing these services to Blue Cross and Blue Shield of Kansas (BCBSKS) effective January 1, , Immunization administration through 18 years of age via any route of administration, with counseling by physician or other-qualified health care professional; first vaccine/toxoid component, for BCBSKS, should be billed for the initial ADMINISTRATION ("injection") , each additional vaccine/toxiod component, for BCBSKS, should be billed for each additional ADMINISTRATION ("injection") administered on the same day as the , Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid), for BCBSKS, should be billed for the initial ADMINISTRATION ("injection") , each additional vaccine (single or combination vaccine/toxoid), for BCBSKS, should be billed for each additional ADMINISTRATION ("injection") administered on the same day as the Maintaining the "per administration/injection" definition from the 2010 immunization administration codes (90465/90466, 90471/90472) will allow a budget neutral conversion. The 2011 allowances will reflect a 1% increase. $10.69 for the initial injection (90460) $8.82 for each additional injection (90461) administered on the same day $9.27 for the initial injection (90471) $8.82 for each additional injection (90472) administered on the same day These administration codes should be reported on the same claim, in addition to the vaccine/toxoid code(s) Unit limitation(s) will be applied to all codes. For a listing of unit limits, see: NOTE: + - INDICATES THIS CODE IS AN ADD-ON CODE TO THE PRIMARY ADMINISTRATION CODE Authenticating a Provider SOMETHING OLD When a provider calls Blue Cross and Blue Shield of Kansas (BCBSKS) they are authenticated before assistance is provided with their inquiry. The same is true for Web inquiries. This has been going on for many years and is nothing new to our provider community.

4 January 24, 2011 Blue Shield Report S-1-11 Page 4 Authenticating a Provider, continued SOMETHING NEW Starting January 24, 2011, BCBSKS will require the same authentication step on ALL written inquiries. This will include anything from a claims status request to a predetermination. The one piece of information we need from the provider to authenticate a written inquiry is either the National Provider Identifier (NPI) or the Tax Identification number. When this information is not included in the inquiry, the inquiry will be returned to the provider asking you to resubmit your inquiry with this information for authentication purposes. It is always our intent to provide you with the best service possible while still complying with industry regulations. If you have any questions regarding this new authentication process, please contact your provider representative. Please be sure to share this newsletter with anyone in your facility who might be submitting written inquiries to BCBSKS. Autism Rider for SOK Pilot Benefit In an attempt to clarify and outline the current State of Kansas (SOK) Autism pilot benefit, listed below you will find the SOK employee benefit rider for Autism services. Autism Rider This rider outlines the coverage provided for treatment of autism in covered children under the age of Nineteen (19). Unless otherwise specified all other provisions of the Benefit Description apply to benefits outlined in this Autism Rider, including deductibles, copays, coinsurance, network provider arrangements and prior authorization. Definitions: Autism Spectrum Disorder means the following disorders within the autism spectrum: Autistic disorder, Asperger s syndrome, and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), as specified within the diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR), of the American Psychiatric Association. Applied Behavior Analysis (ABA) means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior.

5 January 24, 2011 Blue Shield Report S-1-11 Page 5 Autism Specialist means a person who: Has at least a masters degree in human services or education or fully Board Certified Behavior Analysis; and Maintains all standards, certifications, and licenses required for their specific Professional field; and Has successfully completed the state approved curriculum and passed the test with a score of at least 80%; and Has 2,000 hours of supervised experience working with a child with an Autism Spectrum Disorder; and Has successfully passed a background check with the Kansas Bureau of Investigation (KBI), or Adult Protective Services (APS), or Child Protective Services (CPS), or Kansas Department of Health and Environment (KDHE), or the Kansas Nurse Aid Registry, and the Motor Vehicle screen; and Is a Medicaid Enrolled Provider Comprehensive Assessment means completion (by an appropriate professional) and submission of results of: A Vineland II Survey Interview Adaptive Behavior Scales by an qualified evaluator who is a level 3 user based on the Pearson Assessments; and An IQ Test (optional); and A Neurological evaluation by a medical doctor to rule-out primary neurological disorder; and A lead poisoning assessment; and A Speech Assessment to rule-out primary speech disorder; and A Hearing Assessment to rule-out primary hearing disorder; and DSM-IV Diagnostic Criteria; and An Assessment by one of the following: o Checklist for Autism in Toddlers (CHAT); or o Childhood Autism Rating Scale (CARS); or o Modified Checklist for Autism in Toddlers (M-CHAT); or o Screening Tool for Autism in two-year olds (STAT); or o Social Communication Questionnaire (SCQ) (recommended for children four-years of age or older); or o Autism Behavior Checklist (ABC); or o Gilliam Autism Rating Scale (GARS); or o Autism Diagnostic Observation Scale (ADOS); or o Autism Diagnostic Interview Revised (ADI). o Autism Spectrum Screening Questionnaire (ASSQ); or o Childhood Asperger Syndrome Test ( CAST); or o Krug Asperger s Disorder Syndrome (KADS); or o Australian Scale for Asperger Syndrome (ASAS); or o Asperger Syndrome Diagnostic Scale (ASDS). o Pervasive Developmental Disabilities Screening Test (PDD-ST). Intensive Individual Service Provider means a person who: Has at least a bachelors degree in human services or education; and Maintains all standards, certifications, and licenses required for their specific license/certification; and Has successfully completed the state approved curriculum and passed the test with a score of at least 80%; and Has 1,000 hours of supervised experience working with a child with an Autism Spectrum Disorder; and

6 January 24, 2011 Blue Shield Report S-1-11 Page 6 Has successfully passed a background check with the Kansas Bureau of Investigation (KBI), or Adult Protective Services (APS), or Child Protective Services (CPS), or Kansas Department of Health and Environment (KDHE), or the Kansas Nurse Aid Registry, and the Motor Vehicle screen; and Adheres to the DBHS/CSS training and professional development requirements; and Is a KMAP (Kansas Medicaid Assistance Program) Enrolled Provider for intensive individual supports; and Works under the direction and supervision of an Autism Specialist. Periodic Assessment means an evaluation that shows an assessment of the improvement in the individual based upon the diagnosis and approved treatment plan. Timing of the periodic assessments will be based upon the treatment plan, but no less than every six months. Statistically significant improvement in the stated goals and objectives of treatment must be achieved to authorize continued treatment. A Vineland II Survey will be required on at least an annual basis. An annual IQ test is optional. Treatment Plan means a submission by a provider or group of providers and signed by both the provider(s) and parent(s)/caregiver(s) that includes: the type of therapy to be administered and methods of intervention, the goals, including o specific problems or behaviors requiring treatment o frequency of services to be provided o frequency of parent or caregiver participation at therapy sessions o description of supervision, and periodic measures for the therapy, including the frequency at which goals will be reviewed and updated, who will administer the therapy, and the patient s current ability to perform the desired results of the therapy. Benefit Provisions: Autism Spectrum Disorder (ASD): Coverage is available for the diagnosis and treatment of ASD as defined. Diagnosis shall be the appropriate listed assessment instrument from the listed options, performed by an appropriately licensed medical provider. Benefits must be pre-approved by the Plan and may include Applied Behavioral Therapy, developmental Speech Therapy, developmental Occupational Therapy, or developmental Physical Therapy as appropriate. Periodic re-evaluations and assessments are required and continuous improvement must be shown in order to qualify for continued treatment. Results of a Vineland II Survey will be required for the initial assessment to establish a baseline and must be repeated at least annually to establish improvement. Services are limited as follows: Coverage limits for Network and Non Network services combined: Children under age 7 limited to $36,000/year Children age 7-19 limited to $27,000/year Children age 19 and over, not covered All services are subject to the applicable deductible, coinsurance and copay arrangements of the health plan. Providers will be reimbursed based upon network status.

7 January 24, 2011 Blue Shield Report S-1-11 Page 7 All health claims with a diagnosis of Autism Spectrum Disorder will be subject to the limitations stated above. Prior Approval: To qualify for this benefit, a comprehensive assessment may be required (see submission guidelines below). The treatment plan must be submitted to the Plan Administrator in advance of the initiation of treatment and outline measurable goals and objectives for treatment of the member. Benefits will be provided for the initial Comprehensive Assessment whether or not the member is approved for continued treatment. If approved for continued treatment, benefits will be available only for services received following the approval of the treatment plan.* The provider must submit: For newly diagnosed members with eligible autism diagnosis, a Comprehensive Assessment must be completed and submitted within 90 days of treatment beginning under this rider. All members must have a treatment plan detailing the individuals who will be performing the various therapies and/or interventions and the type and frequency of the services to be performed. Services must be pre-approved by the health plan. Periodic Assessments must be submitted no less than every six months and include objective evidence of progress (a Vineland Survey). Exclusions: Respite care Vocational rehabilitation Residential care Transportation Animal based therapy programs Hydro Therapy Camps Vitamin Therapy Programs and/or services administered within the Public, Private or Home School Vocational or Job training programs Services provided by relatives To further clarify, all services by eligible CAP providers, i.e., speech pathologists, physical therapists, occupational therapists, MDs, DOs, etc., may be covered when submitted with an autism related diagnosis (299.00, , , , , ) and will apply to the yearly coverage limitation. These pilot benefits are applicable for State of Kansas employees only. Should you have additional questions regarding the SOK autism pilot, please contact New Directions Behavioral Health at *Prior approval requests must be submitted to New Directions Behavioral Health, P O Box 1627, Topeka, KS , OR can be faxed to NDBH at in advance of the initiation of treatment under this plan.

8 January 24, 2011 Blue Shield Report S-1-11 Page 8 Diagnosis Code V72.62 BCBSKS does not recognize V Laboratory examination ordered as part of a routine general medical examination. This code is non specific and not usable in processing preventive service benefits for our insured. Modifier 33 Preventive Service BCBSKS does not recognize modifier 33. If a provider is billing for a service that is not on the BCBSKS recommended preventive service coding guide, the service should be filed with modifier 22. Workshop Opportunities Workshop Change The 2011 Insurance Billing Workshop in Wichita originally scheduled for May 12, 2011 has been moved to Friday, May 13, Same time, same location. You may register for the workshop on the Web site at