April 23, Questions regarding this document? Contact us at: Provider Network Education - July 2014

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1 QUESTION April 23, Caller: Will precert authorization be required for emergency ambulance or just hospital admissions? 2 Caller: Can we go over who will be considered the HOST Plan and who would be the HOME Plan? 3 Caller: Is there a way to check if a patient has the suitcase or BlueCard ability without having an identification card? We currently use a 270 connection. 4 Caller: We are an ambulance company and have a question about the Availity website. We do not always get a copy of the member ID card and when we submit to the local Blue Plan we get a denial telling us to submit it to the address on the back of the members ID Card. The old Blue Cross website gave us the old address and phone number, but Availity does not give that information. Are you thinking about enhancing Availity to provide this information? 5 Caller: I have a question about running eligibility on Availity for patients that have Prudent Buyer for Pinnacle and they have only 1 alpha prefix instead of 3. How do you run eligibility for that in Availity? 6 Caller: We have a question when we verify eligibility online we don t see that the patients have a deductible. Where can we find that information? 7 Caller: We are a Specialty Pharmacy and submit BlueCard claims to the plan service area where the ordering physicians claims are denying saying we are a remote provider and need to submit claims to our local plan. Do ANSWER Anthem Blue Cross: Right not the requirement is only for inpatient admissions, but I anticipate it will be required for ambulance in the future. Anthem Blue Cross: The HOME Plan is where the members benefits are held, the HOST Plan is where the service actually takes place. Anthem Blue Cross: The suitcase is a visual indicator that is only shown on the member s ID Card. Anthem Blue Cross: Not at this time. It is an enhancement that we are looking into, but for right now you would need to call the number on the back of the members ID card to get that information or if a BlueCard member then contact Anthem Blue Cross: I have not seen 1 alpha prefix and request that you send an to network.education@anthem.com with an example of this. Anthem Blue Cross Are you checking this on Availity? That information is under Benefit Detail, I can show you where that is located, send an to network.education@anthem.com and I will provide that information to you. Anthem Blue Cross: That s correct according to the Network Update that was posted in 2012 Specialty Pharmacy should be filing their claims where the ordering rendering physician is located. marks of the Blue Cross Association. Page 1

2 you have any other Specialty providers that have those issues? The home plan will not accept us as a specialty pharmacy and tell us we need to submit to our local, meaning California, we are submitting claims to the home plan where the referring physician is and those home plans are not accepting the claims and are telling us we should be billing as a remote provider and bill California. They are trying to keep the claim in network versus out of network because we don t hold a contract with those home plans. Caller: But those plans are not accepting them. 8 Caller: I am a little confused about claims submission. We are a professional radiology group and we actually bill our claims to the local and any time we submit an appeal or grievance to the CA address they always come back to us through correspondence in the mail indicating we must forward those grievances and appeals to our local Blue Cross and Blue Shield wanted to know if this is a correct process being a Wisconsin professional Medical group. We are a Wisconsin provider. 9 Caller: Is there anywhere we can get a copy of the presentation itself, not the handouts 10 Caller: Is everybody, every patient that has a Blue Cross or Blue Shield card considered part of the BlueCard program? Anthem Blue Cross: That would be an Escalation issue, and I can find resolution for you. Call in and let that rep. knows that this call needs to be escalated and we will 0see if a system fix is required. You can your example and we will get that issue resolved for you. Anthem Blue Cross: We mentioned earlier the procedure for Ancillary providers Do you file you claims on a 1500? Your claims should be filed where you submit your appeals. There are sometimes where members home plan and your contract aligns in the Wisconsin area where it may be contract specific. Anthem Blue Cross: Absolutely, upon request, you can send an and we will send you a link to this recorded webinar. Anthem Blue Cross: Sometimes the plans are very specific to the area, some members contract policies are very specific to a particular region, so for a general answer, for traditional PPO, but there are exceptions. If a member is carrying a Blue ID card then that ID card should include a 3 character alpha prefix at the beginning of the member id number, an appropriate suitcase, some may have Medicare Advantage products and those products are marks of the Blue Cross Association. Page 2

3 processed against different contracts and governmental rates as opposed to your contract with Anthem Blue Cross, so there are some limited exceptions. If you are presented with a member ID card that is not a standard PPO or traditional product we encourage you to check edibility and benefits to determine what type of product the member is enrolled in. Caller: Does the suitcase make that identifiable as a BlueCard program participant? 11 Caller: I have a question regarding the BlueCard National customer service escalation contact list. What requirements do you have in order to have that call escalated? I know with our local we have to have reference number from the claims rep and then have the supervisor to be contacted and if the supervisor does not resolve the issue then it can be escalated. With BlueCard is that the same, because it is not noted on your handout here? Anthem Blue Cross: Yes, and we briefly went over what the letters in the suitcase mean in today s presentation. You will find additional information in the Quick Guide to Blue Cross and or Blue Shield Member ID Cards, located in the handouts. Anthem Blue Cross: That s a good question. There is a 3 tier process Frontline, if they are not able to handle your issue then have a Team lead or Supervisor offshore assist, if that Team Lead or Supervisor is not able to handle offshore, then it is handed over to a vendor return personnel onshore, meaning in the US. This is all they do, they are senior level reps, they don t have the title as Supervisor but they can do just about everything a supervisor can do and then there is me, and if it gets to me then it is pretty escalated and we don t go beyond. What I do is supervise the de-escalation process for all the BlueCard California, Colorado & Nevada. If it does get to me then I do need reference numbers and reps. so that we can educate our reps and determine why it was escalated to my level. Yes there is a process. Caller: What do we do if we have multiple claims that are the same issues? Does it go through individual claims reps to tell you and go through the process? 12 Caller: There was a question earlier about Pinnacle claims and I wanted to know if I could provide the website that we use to verify Anthem Blue Cross: That s a good question. We just implemented a work flow where the rep. should be asking for a spreadsheet with all claims that are affected with appropriate information. Let the rep know you have a spreadsheet and that would be an escalated issue that would be handled by a Senior Level rep or Supervisor because you have 10 or more claims that have the same issue. Anthem Blue Cross: Feel Free. Caller: webopis@pennacletpa.com Anthem Blue Cross: Can you send that information to our mailbox as well I would like to marks of the Blue Cross Association. Page 3

4 eligibility. 13 Caller: A lot of our claims, medical records, a lot get denied for medical records. Blue Cross does not only deny for precert, Blue Cross always says they never received the records, how can we get Blue Cross the records that they need? research that. Anthem Blue Cross: Are you indicating clams are denied needing medical records? You mail them and we say we don t have them? Caller: Once we call them they say they never received the records so we mail them again and they can t find them again, some reps. provide a fax and those seem to go through fine which is very frustrating. Caller: Being in the electronic world this is just a thought, we should be able to just upload medical records on Availity just like we can upload a question about a claim on Availity. 14 Caller: We have difficulty because we wonder if they should be processed by Blue Cross or Blue Shield we are not participating provider for Blue Shield. Sometimes we will get payment from a carrier that we did not send the claim to. Anthem Blue Cross: That whole issue has been brought to the for-front and I am working with them on that issue of missing mail. Anthem Blue Cross: That is a process that we have through MEA, now back to your question about faxing, that is a process that happens when you ve indicated you have mailed it and we don t have it, then faxing is offered, but the problem with faxing is there is no real way to confirm receipt. Your fax could be working, but ours could be down. We don t want to violate HIPAA, so that process is a courtesy when you are still on the phone, the rep. may indicate because you are having this problem, hey ma m would you like to put me on hold and fax that information over and we can confirm receipt while you are on the phone. If you have a tracking number of FedEx or mailed Priority, we can move that issue up to the de-escalation process and we will get your issue resolved. Anthem Blue Cross: Anthem Blue Cross and Blue Shield are competitors in the state of California. We will always tell you to submit your claims here to Blue Cross and if Shield was to process that members claim then we will let you know. There are some Employer groups that specifically indicate they only want Cross or Shield to handle their claims. If this is the case and we will send notification that Shield is to handle this claim. Caller: We have never received that communication, we just get the EOB from Shield indicated they have processed it. Anthem Blue Cross: We don t forward the claim to Blue Shield. You may want to check with your billing service or clearing house to see where the claim is being sent. marks of the Blue Cross Association. Page 4

5 Caller: how can I find out ahead of time if it belongs to Cross or Shield? Caller: Ok so we are not a Blue Shield member and we bill Shield, can we balance bill the member? May 21, Caller: I have a question regarding Exchanges. I submit to the medical group and nothing happens. We are an out of network California doctor s office and I am starting to get claims denied with a note that indicates providers who do not have a participating agreement with the state plan in which the members have coverage must file claims for members whose ID began with a three digit alpha prefix with your local Blue Cross/Shield Plan for processing through the BlueCard program. For years we have been sending all of our BlueCard claims to the local address in Los Angeles, all of our Blue Cross plans have alpha prefix, do I just have to change it so that it says BlueCard on the address so that it can get processed? Caller: So I think I need to go on the website to verify the member s benefits first. 2. Caller: We are here in California and based on the alpha prefix we have always submitted claims to either Blue Cross or Blue Shield, the local. It was always based on the alpha prefix, but now we are noticing we are getting a notice from Blue Cross indicating the claim should go to Blue Shield. Are you no longer forwarding the claims to shield for processing? Anthem Blue Cross: You can find out ahead of time by checking the Blue Card Claim Advisor on ProviderAccess under the Overview tab. Enter the alpha prefix and it will let you know if the claim should go to Anthem Blue Cross or Shield. Anthem Blue Cross: Your EOB should serve as your guide Anthem Blue Cross: It sounds like the membership may have renewed or updated like the member benefits may have changed and that prefix no longer applies. The member may now have a different ID. Anthem Blue Cross: Yes, that would be best. Anthem Blue Cross: That is correct, we no longer forward the claims to Blue Shield for handling. A letter is sent to you indicating the claim belongs to Blue Shield. marks of the Blue Cross Association. Page 5

6 Caller: Do you have a place where we can enter the alpha prefix to see where the claim should be sent? 3. Caller: I have a question about the fee schedule. We are providing service to a BlueCard patient from out of state, is our payment fee schedule going to go off of the California fee schedule? Caller: But the allowable will be based on whatever the California allowable, correct? Caller: We are a Home infusion provider and we sometimes see from states that we are paid lower than the contracted rate. 4. Caller: We are participating, but have an outof-network provider that we work with and have noticed that when submitting claims to different home plans we are having problems getting EOBs, and we were under the impression that whether the checks were sent to the provider or member according to AB1455 we were entitled to an EOB. Anthem Blue Cross: Yes, that is available on ProviderAccess under the Overview tab, it is call BlueCard Claims Advisor, just enter the prefix and it will tell you if it belongs to BlueCross or Blue Shield. Anthem Blue Cross: That s a good question, we do recommend pricing based on your fee schedule, that then becomes the allowed amount for the home plan to approve, but because both contracts must align, that is your fee-schedule and the members contract to consider what benefits they have and as long as they have benefits then the benefits will apply: reimbursement rate, deductible, coinsurance, copay, and or limitations. Anthem Blue Cross: Depending on the provider if you are out of network then it will be based on usual and customary and if you are in-network then it will be based on the provider s contract. Anthem Blue Cross: We would suggest you give us a call to take a look at those claims where you feel the contracted allowable was not considered. Anthem Blue Cross: We want to make sure you are aware of the difference between an EOB and a remit. The EOB s are submitted to our contracted providers and our members there is a distinction between the two. A remit is a brief summary of what happens, it does not go into detail and you should be able to obtain it online. I would encourage you to call to get additional information from what you see on the remit as a non par provider. Caller: Yes, but when we call, the reps. indicate they are unable to give us that information due to HIPAA regulations. 5. Caller: Is it mandatory to call in to get insurance benefits? Anthem Blue Cross: That is a concern, and I will note that as an educational opportunity for our off-shore reps You filed the claim and you should be privy to that information. Some of the information they provide should be filtered to a degree, such as membership information but general information should be given to you. Anthem Blue Cross: No it is not mandatory. It is a better business practice to verify benefits ahead of time, so that you don t run into having to track the member down marks of the Blue Cross Association. Page 6

7 6. Caller: I work for an ambulance provider; we are contracted with our local Primera Blue Cross in Washington and are experiencing problems with payment between Home and Host plan. Some of the claims are not paying at out contracted rate. 7. Caller: We seem to be having issues now that we have switched checking eligibility to Availity. We are not getting any information for BlueCard members when checking through Availity. June 25, Caller: I was thinking you were going to touch on the Health Insurance Market Place: 2. Caller: My question is related to waiting periods for home health care as is it relates to BlueCard, we are in California. We have patients from all over and have experienced issues when verifying benefits and are notified of a waiting period for home health services. We get an authorization prior and bill the insurance company after services are rendered and are getting penalties, up to a $ per patient because we did not follow a waiting period before we saw the patient. This could vary from 24 to 72 hours. This information is kept from us at the start of care. We are not giving this information. How do we obtain this information ahead of time? because they have an amount they are responsible for. You can also view they members Evidence of Coverage on Availity when checking the members benefits. This is the actual member s benefits booklet and you can check to see what or if it indicates this Anthem Blue Cross: If there is a payment discrepancy based on your contract then you need to go back to Washington. They may be looking at emergency versus non-emergency, or the limitations and or benefits on the member s contract. Anthem Blue Cross: Please send that information directly to our mailbox network.education@wellpoint.com and I can call you and we can walk through the Availity Web Portal together. Anthem Blue Cross: The only time BlueCard would be effective with this is in emergency situations. This product is very limited to the local setting Anthem Blue Cross: Are you asking the specific question does a waiting period apply to this service? Caller: Yes, and the response that we are getting is not that we are aware of, and that it is the patients responsibility to know what Anthem Blue Cross: This is being referred to Scott K. Anderson for review and response. marks of the Blue Cross Association. Page 7

8 their benefits are. Of course, the patient does not know this and the penalties are processed as patient responsibility. This causes a big problem because we notify the patient in advance of service what their responsibility will be. So they are not expecting that additional cost of the penalty being assessed. 3. Caller: I have 2 questions. When we get a patient that we verify benefits on, we are not sure if it should go to Blue Cross or Blue Shield. We will bill it Blue Cross and get checks from Blue Shield, we are billing electronically. Anthem Blue Cross: We no longer forward to Blue Shield for handling. What we do is send you notification that this claim should be processed by Blue Shield and request you to send. I am not sure why you would see that and would need to see an example of that. Caller: Yes I will see 2 children from the same family, same plan, and one will have a check sent to us from Blue Cross and the other Blue Shield. Caller: OK my second question is we are a pediatrics office and when we go online to verify benefits, the information is not accurate. This is occurring on Availity. It will indicate $ per visit. When I call after I receive and EOB they indicate no, it is $ per year. Well that is not what was indicated on the Availity. I have print out showing this. Now, this member is from New York and they will indicate you should have called, but why am I calling when I can verify online. Anthem Blue Cross: Please send examples of that to our Network Education mailbox. Anthem Blue Cross: We apologize and wonder if it maybe that the benefit you are looking at online may not be for the actual benefit you are seeking. Caller: No, it specifically indicates Well Child $ per visit and the benefits that are being applied are $ per year. 4. Caller: Are there some plans with the 3 alpha prefix that is not covered in California. Anthem Blue Cross: Can you send that information to the Network Education mailbox so that we can look at that together? Anthem Blue Cross: It is not the alpha prefix that you need to be concerned with in that case. It is the letters in the suitcase that is on the ID card that you would need to focus on. The letters in the suitcase identifies the type of benefits a member has if they travel outside of their Home Plan or if they have no benefits at all. Later on in the presentation you will have access to the Quick Guide to marks of the Blue Cross Association. Page 8

9 5. Caller: We work with children with autism diagnoses, when I call within California no problem, but when I have to verify benefits for a BlueCard member, they don t understand what benefit to look for. I have calling on a member more than once to verify benefits for autism and take 2 out of 3 responses because they never match. Blue Cross and/or Blue Shield Member ID Cards. This will provide a clearer understanding of the significance of what benefits the member has when traveling. Anthem Blue Cross: What you need to understand is that it is covered under the regular office visit coverage. It is not expressly that it is a covered benefit in other plan areas, but it is a California mandate that we have to cover. So when you are calling in to verify benefits for those H codes, you need to get benefits for an office visit or a specialty office visit. Caller: Now what about on the self-funded plans where the basic plans exclude the benefit, but sometimes employers will write it in, so how does customer service agent look for that benefit? Is there a way when I call in I can tell them something to make it easier for them to find that ABA benefit that is generally excluded on self-funded plans unless it is written in? How can I request that to make it easier for them to find? 6. Caller: We had a similar issue with the checks being sent to Blue Cross and checks coming back from Blue Shield, or vice versa. This was a big problem because we code different for Blue Cross then for Blue Shield. Blue Shield will get the claim and reject it because it is not in the correct format that they accept. We no longer submit electronically because of this. What we found is that it was the clearing house that was changing it. Now Shield won t pay. Anthem Blue Cross: My suggestion is to do what you have been doing and if you are not sure then ask for a Team Lead because it is typically covered under the regular office visit, specialty visit, or physical therapy. Anthem Blue Cross: Have you discussed this with our EDI Department? Caller: What we learned is that is our clearing house is making the error and sending it to the incorrect Blue plan, and now Shield won t reprocess the claim. 7. Caller: Can I submit all BlueCard claims to Anthem Blue Cross Anthem Blue Cross: Then unfortunately you would need to address that with your clearinghouse and Blue Shield. Anthem Blue Cross: Yes, you can marks of the Blue Cross Association. Page 9

10 Caller: Is there a Request For Medical Release HIPAA compliant form that you have on the site that I can use. 8. Caller: I m an OBGYN in California and wanted to know if the BlueCard program is an Off Exchange program? I have a lot of patients that are Off the Exchange. 9. Caller: We have been providers for Anthem Blue Cross for years and years. We are no longer providers under Covered California, but are still participating providers. How is that fair? 10. Caller: In regards to turnaround time for processing claims according to the Department of Insurance of CA under section , Standards for Prompt, Fair and Equitable Settlements. I want to know if the turnaround time for BlueCard claims is the same 30/45 Calendar days, but the reps. are telling me it s 30/45 business days. Anthem Blue Cross: yes, that form is on anthem.com/ca and we will provide the link for you shortly. Anthem Blue Cross: I have a number that will assist you with Exchange issues or concerns as far as who you should be able to handle. This is our Network Relations number Anthem Blue Cross: If I may jump in, this question does not sound BlueCard related, you will need to contact Provider Relations at directly. Anthem Blue Cross: So your questions is does Prompt Pay apply to the claim regardless of the state you are in, and the answer is yes. marks of the Blue Cross Association. Page 10