Transcription of BCBSND Provider Manual
1 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association BND-22-0074565 8-22 Provider Manual i TABLE OF CONTENTS INTRODUCTION .. 1 Disclaimer .. 1 Confidentiality of Member Information .. 2 Compliance with the Confidentiality of Substance Use Disorder Patient Records Rule (42 Part 2) .. 2 ACCREDITATION .. 3 COMMUNICATING WITH BCBSND .. 3 Electronic Benefit Verification Availity Essentials .. 3 BlueCard Eligibility Line .. 4 Electronic Claims Filing with Availity Essentials Intelligent Gateway .. 4 Member Services .. 4 BCBSND Provider 4 Use NPI When Calling BCBSND Provider Service .. 4 FEP .. 5 Member Precertifications .. 5 Medical Surgical .. 5 Case Management .. 6 Behavioral Health .. 6 Managed Benefits & Medical Management .. 6 Provider Networks .. 6 Credentialing/Recredentialing/ Provider Directory Changes.
2 7 Provider Relations Services .. 7 Provider News Blasts .. 7 Provider PARTICIPATION .. 8 Provider Group Participation Agreements .. 8 Network Exhibits .. 8 Submitting claims for BCBSND members .. 8 Accepting BCBSND s payment plus the member s deductible, coinsurance and/or copayment, if applicable, as payment in full for covered services .. 9 Modifications to Provider Agreements and Fee Schedules .. 9 Member Discrimination .. 9 Provider Member Communications .. 9 ii Provider Dispute Resolution Process .. 9 Nonparticipating Providers .. 10 Contiguous Counties .. 10 Claims filing rules for counties bordering North Dakota .. 10 Credentialing Program .. 11 Provider Participation Status .. 12 Participating: .. 12 Non-participating: .. 12 Non-payable: .. 12 Credentialing and Recredentialing Process .. 12 Tips to Avoid Delays .. 13 While You Wait.
3 13 Provider Availability Standards .. 13 Access and Availability Standards .. 13 Appointment Availability and Access Standards .. 14 Provider Directory .. 15 Provider Change Notification .. 15 Refer Members to Participating Providers .. 16 Federal Employee Program (FEP) .. 16 BlueCard Program .. 16 How to Identify BlueCard Members .. 17 Prefix .. 17 International Blue Plan Members .. 17 ID cards with no Prefix .. 18 Suitcase Logo .. 18 HMO patients serviced through the BlueCard Program .. 18 How the Program Works .. 18 BlueCard Claims Submission .. 19 Ancillary Claims Filing Instructions for BlueCard Claims .. 19 Easy Access to Medical Policy and Precertification/Precertification Information for Out-of-Area Blue Members .. 20 Call 800-676-BLUE (2583) to obtain eligibility only or if you need both eligibility and precertification: .. 20 iii Medicare Advantage (MA) Members from NextBlue of North Dakota (NextBlue) and Out of State MA Blue Plans.
4 20 Frequently Asked Questions Regarding Treatment of Medicare Advantage Members .. 21 Providers must include the following data elements on Medicare Advantage claims, when applicable: .. 22 ELECTRONIC CLAIMS SUBMISSION & PAYMENT .. 23 Availity Essentials Intelligent Gateway .. 23 Availity Essentials Provider Portal .. 23 Electronic Funds Transfer .. 23 CLAIMS SUBMISSION .. 24 Tips for Submitting Paper Claims .. 24 For professional paper claims: .. 24 The following tips will ensure prompt and accurate OCR translation of your CMS-1500 claims: .. 25 Verifying Member ID 26 Examples of ID numbers: .. 26 Timeframe for Claims Submission .. 27 Procedure and Diagnosis Codes Guidelines .. 27 ICD-10-CM (Diagnosis Codes) .. 27 ICD-10-PCS (Procedure Code Structure) .. 27 Add-on Codes .. 28 Trailing - T Codes .. 28 Modifiers .. 29 National Provider Identifier (NPI).
5 29 Coordination of Benefits .. 30 Coordination of Benefits (COB) Guidelines .. 31 BlueCard Coordination of Benefits (COB) .. 31 Subrogation .. 32 Accident/Workers Compensation .. 32 Medicare Supplemental Claims .. 32 For out-of-state BCBS members .. 33 How to determine if the claim was crossed over from Medicare .. 33 The following claims are excluded from the crossover process for BCBSND : .. 33 What to do when the claim was not crossed over from Medicare .. 33 iv Follow-up on crossover claims .. 33 Claim Adjustments/Correction Process .. 33 Professional Claims .. 33 Institutional Claims .. 34 Out-of-State BCBS Members and Fully Rejected Claims .. 35 Institutional .. 36 Professional .. 36 Things to Note .. 36 Submitting NPI & Taxonomy Codes on Claims .. 36 DOCUMENTATION .. 37 Documentation Requirements .. 37 Diagnostic Imaging .. 38 Demographics.
6 38 Clinical Information: .. 38 Eight-minute rule for Physical, Occupational and Speech Therapy CPT codes based on 15-minute units: .. 39 Medical Record Documentation Policy .. 39 Evaluation and Management (E/M) Documentation Requirements .. 40 Amended Medical Records .. 40 REIMBURSEMENT & BILLING GUIDELINES .. 41 41 General .. 41 Member Cost-Sharing .. 41 NCCI Edits .. 41 National Drug Code .. 41 Not Otherwise Specified (NOS) and Not Otherwise Classified (NOC) .. 42 Professionals in Training .. 42 Billing for Services Provided to Immediate Family Members .. 42 Provider -Based Status .. 44 Critical Access Hospital Status .. 44 Rural Health Clinic .. 44 Incident to Billing .. 44 Member-Demanded Services .. 45 Surgical Roll-up Methodology .. 46 v Trauma Activation .. 46 Waivers and Discounts .. 47 Reimbursement Policies & Billing Guidelines.
7 47 Ambulance .. 48 Chiropractic .. 48 Dialysis Services .. 48 Durable Medical Equipment (DME) .. 48 Endoscopy/Multiple Endoscopies .. 49 Home Health Services .. 49 Home Infusion Therapy .. 49 Hospice Services .. 50 Inpatient Skilled Nursing Facility Billing .. 50 Inpatient Swing Bed Hospital Billing .. 50 Inpatient Transitional Care Unit Hospital Billing .. 51 All Patient Refined-Diagnosis Related Group (APR-DRG) .. 52 Overview .. 52 Coding Elements .. 52 Present on Admission (POA) Indicator .. 53 Transfer Cases .. 53 Outlier Cases .. 54 Billing Guidelines .. 54 Enhanced Ambulatory Patient Group (EAPG) .. 56 Overview .. 56 Billing Guidelines .. 56 Significant Procedure Consolidation .. 56 Same significant procedure consolidation will occur when multiple occurrences of the same significant procedure EAPG are present on a claim. The highest weighted significant procedure EAPG will be paid in full and any subsequent occurrences of that same significant procedure EAPG will be consolidated and receive no payment.
8 BCBSND applies Same Significant Procedure (SSP) for Significant Procedure type (2) and Diagnostic type (25).. 56 Ancillary Packaging .. 57 Ancillary Discounting .. 57 CARE COORDINATION .. 57 vi Case Management .. 57 Prenatal Plus .. 58 Enrollment .. 58 Disease Management .. 58 How It Works .. 59 Utilization Management Program .. 59 Notification Responsibility .. 59 Precertification & Concurrent Review/Discharge Planning .. 60 Retrospective Utilization Management .. 61 Predeterminations .. 61 Peer to Peer Process .. 62 Failure to Comply with Utilization Management Requirements .. 62 Authorized (Network) Referrals .. 62 Referral Guidelines .. 62 Emergency Services .. 63 Levels of Payment .. 63 Medical Records .. 63 BlueAlliance .. 64 Pharmacy Management .. 64 Pharmacy Network .. 65 Drug Formulary .. 65 Utilization Management Programs.
9 65 Medical Policy .. 65 Retired Medical Policy .. 66 Draft Medical Policy .. 66 Medical Necessity Criteria .. 66 Technology Assessment Evaluation Criteria .. 67 QUALITY MANAGEMENT .. 67 Quality Measures .. 68 Patient Experience Surveys .. 68 Blue Distinction Specialty Care .. 68 Member Grievance .. 69 SPECIAL INVESTIGATIONS UNIT (SIU) .. 69 vii Objectives .. 69 Provider Audit and SIU Process .. 70 Audit Process .. 70 Reconsideration Process .. 70 Self-Audit .. 71 Audit Processes .. 71 DRG Coding Audit .. 72 Audit Processes .. 72 DRG Audit Reconsideration Process .. 72 First Level of Reconsideration .. 72 Second Level of Reconsideration .. 73 Independent External Review .. 73 Rebilling Process .. 73 DRG Coding Review .. 73 APPEALS .. 73 Overview .. 73 Provider Inquiry and Appeal Process .. 73 Inquiry .. 73 Pre-Service Claim for Benefits Inquiry.
10 74 Retrospective Review Claim for Benefits Inquiry .. 74 Post-Service Claim for Benefits Inquiry .. 75 Appeal .. 75 Appeal Process .. 74 Federal Employee Plan Disputed Claims Process/Guidelines .. 75 Write to OPM at: .. 77 Independent External Review Process .. 77 Independent External Review Provider .. 77 Independent External Review Member .. 78 PREVENTIVE HEALTH BENEFITS AND CODING .. 79 Affordable Care Act (ACA) Essential Health Benefits .. 79 Metallic Products .. 80 Commercial Risk Adjustment .. 80 MEMBER ENGAGEMENT TOOLS .. 81 viii Patient Review of Physicians (PRP) .. 81 Care Cost Estimator (CCE)/ Member Out-of-Pocket (MOP) .. 82 BCBSND HEALTH PLANS .. 82 Employer Group Plans are Referred to as Group Plans .. 82 Large Group Plans .. 82 Small Group Plans .. 84 Individual Plans (Non-employer Sponsored Coverage) .. 84 State and Federal Plans.
