High Tech Imaging Programs - Home - Arkansas … 3 ARKANSAS BLUE CROSS and BLUE SHIELD AHCPII...

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ARKANSAS BLUE CROSS and BLUE SHIELD An Independent Licensee of the Blue Cross and Blue Shield Association

Arkansas Medical Society

10th Annual Insurance Conference

September 24 and 25, 2013-Crowne Plaza-Little Rock

October 9, 2013-Holiday Inn Convention Center-Springdale

October 17, 2013-ASU Convocation Center-Jonesboro

ARKANSAS BLUE CROSS and BLUE SHIELD

Change in Copays and Deductibles Effective 1/1/2014, new deductibles/copays Example: Bronze Plan will have $2000.00 deductible Gold/Silver Plan Specialist copayment increases from

35.00 to 70.00

All Transplants Will Require Pre-Certification All transplants require pre-certification through American

Health Holding

Provider Offset Beginning April 1st ASE/PSE will offset with no notification

Claim Review Provider submit claim reviews to Health Advantage

Members may appeal to Employee Benefits Division (EBD)

ASE/PSE


Medicare Crossovers Effective October 13, 2013, providers are to wait

30 days before submitting claims to ABCBS

Claims received within 30 days of Medicare RA

date will be returned or rejected

Questions Regarding Medicare Crossovers

501.378.2127 or 800.880.0918

BlueCard®

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Traditional Wellness

Only diagnosis specific

PPACA Wellness

Specific diagnosis and CPT codes

Lab

March 2013 Providers’ News

AHIN will specify PPACA or Traditional

AHIN will specify in the wellness area if the plan is

PPACA or Traditional for ABCBS plans

Non-grandfathered/PPACA Wellness


American Health Holding (AHH)

ASE/PSE www.americanhealthholding.com

National Imaging Associates (NIA)

Arkansas BCBS, Health Advantage Commercial,

Exchange Metallic Plans, USAble Life Group Health,

Medicaid Private Option, Medicare Advantage PPO

(NE Region) eff 1/1/14 www.radmd.com

AIM Specialty Health (AIM)

Walmart, Tyson, Boeing, Anthem

www.aimspecialtyhealth.com

Blue Advantage/Self Funded Groups Check back of the card

High-tech Radiology


Flu Shot Administration Billing: G0008 Adults Over 18 for the administration with dx V04.81 90460—90474 Children (18 and under): Use the appropriate

90000 CPT Code for administration with dx V20.2

Flu Shot Vaccine Billing: • 90655 Trivalent, split virus, children 6-35 months of age,

intramuscular • 90656 Trivalent, split virus, 3 years and older, intramuscular

• 90657 Trivalent, split virus, children 6-35 months, intramuscular • 90658 Trivalent, split virus, 3 years and older, intramuscular • 90660 Trivalent, live, for intranasal • 90672 Quadrivalent, live, intranasal • 90686 Quadrivalent, split virus, 3 years and older, intramuscular

When it is necessary to bill multiple occurrences of 90460-90474 on the same date of service for the same member, please bill the second and

subsequent occurrences with modifier 59

Flu Vaccine Administration 2013-2014

http://www.americanhealthholding.com/

http://www.radmd.com/

http://www.americanhealthholding.com/

http://www.aimspecialtyhealth.com/

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AHCPII Arkansas Healthcare Payment

Improvement Initiative

Wave One episodes

• CHF

• Hip/Knee

• Perinatal

Wave One live reporting began 1/1/2013

1st Quarter live reports on AHIN portal

Quality Metrics should be entered via AHIN portal

AHCPII Wave One


AHCPII Arkansas Healthcare Payment Improvement Initiative Wave Two Episodes

• Tonsillectomy/Adenoidectomy

• Colonoscopy • Cholecystectomy

Wave Two In Historical Reporting Phase PAP is physician Preliminary historical reports posted on AHIN

portal Questions: www.paymentinitiative.org or

[email protected]

AHCPII Wave Two


Medicare Compliance Training for Providers Annual Medicare Compliance Training available at

www.arkansasbluecross.com under Provider Resource Center

Training must be completed by all staff by 12/31/2013

New hires must complete training within 90 days of hire

Must submit online attestation stating completion of training

Documentation required to be kept on file for 10 years

Provider voluntary compliance program http://oig.hhs.gov/compliance/provider-compliance-

training/index.asp

Fraud hotline 1.800.372.8321

Fraud and Abuse CMS Compliance Training

http://www.paymentinitiative.org/

mailto:[email protected]

http://www.arkansasbluecross.com/

http://oig.hhs.gov/compliance/provider-compliance-training/index.asp





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Risk Adjustment Mandated by the Affordable Care Act Corrective tool used to mitigate risk and offset the cost of

serving a less healthy population Chronic conditions must be reported every calendar year

(e.g., leg amputation must be reported yearly) Code diagnoses to most specific level

(no unspecified or not otherwise specified )

Medical Record Requests MRRs will be requested throughout the year for Exchange

members Accurate coding will minimize disruption of additional record

requests and claim resubmissions Medipak Advantage MRRs from Inovalon and National

Advantage plans from Verisk

Risk Adjustment


Medi-Pak® Advantage In-home Health Checks In-home personal health check-ups for

Medi-Pak ® Advantage (PFFS & PPO) members

In home lab-draws

Biometric screening

Medication reconciliation

Member’s PCP will receive summary report

Medi-Pak® In-Home Personal Health Check-up


Healthcare Exchange An Exchange is a website where consumers can

go to compare and purchase insurance plans

In Arkansas referred to as Marketplace

http://marketplace.cms.gov/getofficialresources/multimedia/multimedia.html

Qualified Health Plans QHPs are plans on the Exchange that meet the

required 10 Essential Health Benefits

No Medical Underwriting

No Pre-existing

What is an Exchange?



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10 Essential Health Benefits Ambulatory patient services (Dr visits/OP services)

Emergency services

Hospitalization

Maternity and newborn care

Mental health and substance use disorder services, including behavioral health

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory services

Preventive and wellness services and chronic disease

management

Pediatric services, including oral and vision care

Note: No annual or lifetime dollar limits on EHB’s (can have visit limits)

10 Essential Health Benefit (EHB)


On Exchange/Marketplace Plans (receives subsidy)

Arkansas Blue Cross BlueShield

Multi-State Plan

Off Exchange/Marketplace Plans (no subsidy)

Arkansas Blue Cross BlueShield

No Multi-State Plan

Note: Subsidy eligibility is the primary purpose to purchase coverage “on” the Marketplace

Types of Exchanges available in Arkansas


Exchange Enrollment Dates

October 1, 2013 • Open Enrollment Period begins

January 1, 2014 • First effective date of coverage by a Qualified

Health Plan March 31, 2014

• Open Enrollment Period ends for Health Care Exchange

• Open Enrollment Period will end for Medicaid Private Option

Exchange Dates

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On Exchange Plans

Metallic Plans

• Bronze, Silver, Gold, Platinum

• Include the new Medicaid Private Option

• Contract amendments apply to the Individual Metallic QHPs

BlueCross BlueShield Multi-State Plan

Off Exchange Plans

Metallic Plans

Same as on Exchange just no subsidy

ABCBS Exchange Plans


True Blue PPO Network used for Exchange

Contract amendments do not change commercial reimbursement

Exchange members are previously uninsured or under insured or are on Medicaid

The Metallic Plans are on average higher reimbursement than current Medicare payments

No Change to Primary Care

Exchange True Blue Contract Amendments


Exchange Products

Exchange Prefixes are XCB, XCG, XCD, XCQ,

XCR, XCV, AND XCY. Look for the word METALLIC on the card to

identify Exchange Plans.

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90 Day Grace Period

If a member is responsible for payment of a

portion of a monthly premium, a 90 grace period

for claims is in effect

Days 1-30

Claims for providers will be paid in full

Days 31-90

The member is considered uninsured and

providers will see notification on AHIN

After 90 days

Coverage can be terminated for non-payment

90 Day Grace Period


AHIN Online Provider Enrollment Portal New Providers Includes Ancillary Providers Clinic Affiliation

Add Providers to existing clinics Term a Providers clinic affiliation that have

left your clinic

AHIN and EDI electronic mailing list subscription Updates about important changes for EDI

and AHIN

Self-Service Tools


Top Six Claim Denials

Mutually Exclusive Procedure

Medical Information Not Received

Duplicates

Wellness Codes

Medical Information requested from

another provider

Past timely Filing

Top Six Claim Denials

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Re-Reviews and Appeals

Re-Reviews can be requested by phone, email or Claim Reconsideration Form

Appeals in writing or email at: [email protected]

[email protected]

180 days for denials

Re-reviews and Appeals


Ways to Alleviate Claim Denials File Claims Electronically

• Corrected claims

• Secondary claims

Use AHIN

Current Coding Manuals

Timely Response to Medical Record Requests

Providers’ News

Medicare Crossovers will be denied if submitted from the provider prior to being crossed over from Medicare

Alleviate Claim Denials


Reminders

Watch Providers’ News for updates

Watch AHIN alerts

Providers who utilize billing agencies need

to grant AHIN access to those agencies

Use self-service tools

Providers can E-mail customer service for

all lines of business. Email addresses are listed on AHIN or the websites

Reminders



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Questions?

Questions?

High Tech Imaging Programs - Home - Arkansas … 3 ARKANSAS BLUE CROSS and BLUE SHIELD AHCPII...

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