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508C, Important Notice Due To Covid-19 Emergency …

Provider Administration ManualRevised March 2018 BlueCare Tennessee Provider Administration Manual i PROVIDER ADMINISTRATION MANUAL Table of Contents I. INTRODUCTION A. BlueCross BlueShield of Tennessee Statement of Purpose B. Description of Health Plans and Health Plan Sub-Programs 1. BlueCare Tennessee operates two TennCare Program Health Plans. BlueCare TennCareSelect 2. Enhanced Services Programs: CHOICES Long-Term Services and Supports (LTSS) (currently available from TennCareSelect only) Employment and Community First (ECF) CHOICES SelectCommunity (TennCareSelect only) C. General Information 1. Interpretation Services 2. Health Literacy and Cultural Competency Provider Toolkit 3. Medical Referrals 4.

B. Description of Health Plans and Health Plan Sub-Programs 1. BlueCare Tennessee operates two TennCare Program ... and Other Diagnostic Procedures 9. Reimbursement Guidelines for Multiple Procedures 10. Reimbursement Guidelines for Bilateral Procedures ... Eff. 11/1/2017 F. Financial Responsibility for the Cost of Services . VIII. UTILIZATION ...

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Transcription of 508C, Important Notice Due To Covid-19 Emergency …

1 Provider Administration ManualRevised March 2018 BlueCare Tennessee Provider Administration Manual i PROVIDER ADMINISTRATION MANUAL Table of Contents I. INTRODUCTION A. BlueCross BlueShield of Tennessee Statement of Purpose B. Description of Health Plans and Health Plan Sub-Programs 1. BlueCare Tennessee operates two TennCare Program Health Plans. BlueCare TennCareSelect 2. Enhanced Services Programs: CHOICES Long-Term Services and Supports (LTSS) (currently available from TennCareSelect only) Employment and Community First (ECF) CHOICES SelectCommunity (TennCareSelect only) C. General Information 1. Interpretation Services 2. Health Literacy and Cultural Competency Provider Toolkit 3. Medical Referrals 4.

2 Outpatient/Inpatient Behavioral Health Services 5. Prior Authorization 6. Protected Health Information allowable disclosures under Health Insurance Portability and Accountability (HIPAA) 7. Fraud and Abuse 8. Reporting Requirements of BlueCare Tennessee D. Appeals Quick Reference Guide E. Important Contact Information II. HOW TO IDENTIFY A BLUECARE TENNESSEE MEMBER A. Determining Eligibility B. Member Liability C. ID Card D. BlueCare/TennCareSelect Provider Service Lines E. Electronic Data Interchange (EDI) III. PRIMARY CARE MEMBER ASSIGNMENT A. Primary Care Provider (PCP) Membership Listing B. TennCareSelect Care Management Fee C. Primary Care Provider (PCP) Changes IV.

3 BENEFITS A. Covered Benefits B. Benefit Exclusions V. BILLING AND REIMBURSEMENT A. How to File a BlueCare/TennCareSelect Claim 1. Filing Electronic Claims (Required Method) 2. Filing Paper Claims BlueCare Tennessee Provider Administration Manual ii V. BILLING AND REIMBURSEMENT (cont d) B. Tips for Completing CMS-1500/CMS-1450 Claim Forms C. Timely Filing Guidelines D. Medicare/BlueCare or TennCareSelect Dual Eligible Members 1. Medicare/Medicaid Dual Eligible Members 2. Uninsured/Uninsurable Dual Eligible Members E. Third Party Liability (TPL) F. General Billing and Reimbursement Information 1. Current Dental Terminology (CDT), Current Procedural Terminology (CPT ), Health Care Financing Administration Common Procedural Coding System (HCPCS), and International Classification of Disease (ICD) Coding 2.

4 Addition/Deletion/Revision CDT Codes 3. Addition/Deletion/Revision of CPT Codes 4. Addition/Deletion/Revision HCPCS Codes 5. Addition/Deletion/Revision ICD Codes 6. Unlisted, Miscellaneous, Non-Specific, and Not Otherwise Classified (NOC) procedures /Services 7. Special Report 8. Final Reimbursement 9. Faxed, Photocopied and Altered Claims 10. Policy for Quarterly Reimbursement Changes 11. Quest diagnostics Laboratory Billing Guidelines 12. Billing Telehealth Originating Site Fees 13. Non-Standard Billing Requirements 14. Emergency /Non- Emergency G. CMS-1500 Health Insurance Claim Form 1. Sample Copy CMS-1500 (02/12) Version Claim Form 2. CMS-1500 Claim Form Block descriptions (08/05) and (02/12) 3. Data Elements Required for Submitting CMS-1500 Claims H.

5 Completing CMS-1500 Claim Form 1. General Instructions 2. Physical Claim Form Specifications 3. Form Content and Description I. Specific CMS-1500 Claim Form Billing and Reimbursement Guidelines 1. Anesthesia Billing and Reimbursement Guidelines 2. Obstetric Anesthesia 3. Reimbursement Guidelines for Administration of Regional or general Anesthesia Provided by a Surgeon 4. Reimbursement Guidelines for Moderate Conscious Sedation 5. OB/GYN Services BlueCare Tennessee Provider Administration Manual iii V. BILLING AND REIMBURSEMENT (cont d) I. Specific CMS-1500 Claim Form Billing and Reimbursement Guidelines (cont d) 6. Reimbursement Guidelines for Bundled Services Regardless of the Location of Service 7. Reimbursement Guidelines for Bundled Services when the Location of Service is the Practitioner s Office 8.

6 Professional and Technical Components for Radiology, Laboratory and Other diagnostic procedures 9. Reimbursement Guidelines for Multiple procedures 10. Reimbursement Guidelines for Bilateral procedures 11. Assistant-at-Surgery Billing and Reimbursement Policy 12. Reimbursement Guidelines for procedures Performed by Two Surgeons 13. Reimbursement Guidelines for procedures Performed on Infants Less than 4kg 14. Reimbursement Guidelines for Unusual Procedural Services 15. Reimbursement Guidelines for Screening Test for Visual Acuity 16. Reimbursement Guidelines for Visual Function Screening 17. Reimbursement Guidelines for STAT Services 18. Reimbursement Guidelines for Online Evaluation and Management Services 19. New Patient Replacement Edit for Evaluation and Management Services 20. Billing Guidelines and Documentation Requirements for CPT Code 99211 21.

7 Reimbursement Guidelines for Measurement Reporting Codes 22. Modifiers Requiring Special Handling 23. Medically Unlikely Edits (MUEs) 24. Therapy Code Service Reimbursement 25. TennCare Kids Services 26. Injections and Immunizations a. Reimbursement Guidelines for Vaccines and Toxoids b. Reimbursement and Billing Guidelines for Infusion Therapy, Immunosuppressive, Immune Globulins, Nebulizer, Chemotherapy and Other Injectable Drugs c. Reimbursement Guidelines for Non-Injectable Medications when the Location of Service is the Practitioner s Office BlueCare Tennessee Provider Administration Manual iv V. BILLING AND REIMBURSEMENT (cont d) I. Specific CMS-1500 Claim Form Billing and Reimbursement Guidelines (cont d) 26. Injections and Immunizations (cont d) d. Reimbursement Guidelines for Self-Administered Prescription Medications Dispensed and Submitted by a Licensed Pharmacist e.

8 Reimbursement and Billing Guidelines for Radiopharmaceuticals and Contrast Material f. Compound Drugs g. Reimbursement Guidelines for Medications not Requiring a Prescription from a Licensed Physician Regardless of the Location of Service h. Reimbursement Guidelines for Any Prescription Medications Dispensed by a Provider Other than a Licensed Pharmacist when the Location of Service is not the Practitioner s Office i. Vaccine for Children (VFC) Program for BlueCare/TennCareSelect Members Age 18 and Under j. Home Infusion Therapy (HIT) k. Diagnostic Medial Branch Block Injections l. Trigger Point Injections m. Epidural Steroid Injections 27. Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) a. Durable Medical Equipment (DME) and Medical Supplies b. Oxygen, Oxygen Contents, Oxygen Supplies c.

9 Reimbursement Guidelines for Home Pulse Oximetry d. Prosthetics and Orthotics e. Reimbursement and Billing Guidelines for Codes Classified as Durable Medical Equipment, Medical Supplies, Orthotics and Prosthetics without an Established Maximum Allowable 28. Transportation a. Emergency Transportation b. Non- Emergency Medical Transportation (NEMT) c. Billing Guidelines for Ambulance Services 29. Newborns J. Staff Supervision - Requirements for Delegated Services K. Locum Tenens Policy L. CMS-1450 Facility Claim Form M. CMS-1450 Specific Billing and Reimbursement Requirements 1. Hospital Inpatient Acute Care 2. Post-Partum Voluntary Reversible Long Acting Contraceptive Reimbursement (PP VRLAC) BlueCare Tennessee Provider Administration Manual v V. BILLING AND REIMBURSEMENT (cont d) M. CMS-1450 Billing and Reimbursement Requirements (cont d) 3.

10 Neonatal Services Reimbursement 4. Policy on Present on Admission (POA) Indicators 5. Reimbursement Policy for Selected Hospital Acquired Conditions (HACs) Not Present On Admission (POA) 6. Reimbursement Policy for Serious Adverse Events (Never Events) 7. BlueCross BlueShield of Tennessee (BCBST) Facility Fee Schedule Reimbursement Methodology Policy 8. Hospital Outpatient 9. Hospital Outpatient/Ambulatory Surgery 10. CPT Code with Surgery Revenue Code 11. Observation Room 12. Newborn 13. Clinic Visit (Professional Fees) 14. Wound Care Reimbursement Rules 15. Dialysis 16. Hospice 17. Rehabilitative Care 18. Home Obstetrical Management 19. Chemotherapy 20. Skilled Nursing Facility 21. Guidelines for Appropriate Use of G0128 22. Outpatient Rehabilitation Billing Guidelines 23. Multiple procedures 24. Bilateral procedures 25. Surgical Implants 26.


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