Member Provider Policy & Procedure Manual

1 18NW1073 R12/16 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity ProviderPolicy & Procedure Manual is designed to provide information you will need as a participant in the Blue Cross and Blue Shield of Louisiana Member Provider Network it is an extension of your Member Provider use your Manual , first familiarize yourself with the Network Overview and Definitions sections. From that point on, the Table of Contents should direct you to the information you , we send newsletters and informational notices to providers. Please keep this information and a copy of your respective Provider agreement(s) along with your Manual for your reference. Updated office manuals and Provider newsletters may be found on the Provider page of our website at you have questions about the information in your Manual or your participation as a Member Hospital, please call Network Administration at 1-800-716-2299, option 3 or (225) note:This Manual contains a general description of Benefits that are available subject to the terms of a Member s contract and our corporate medical policies.

2 The Member Contract/Certificate contains information on Benefits, limitations and exclusions and managed care benefit requirements. It also may limit the number of days, visits or dollar amounts to be reimbursed. This Manual is provided for informational purposes and is an extension of your Member Provider Agreement. Every effort has been made to print accurate, current information. Errors or omissions, if any, are stated in your agreement: This Manual is intended to set forth in detail Blue Cross policies. Blue Cross retains the right to add to, delete from and otherwise modify the Member Provider Policy & Procedure Manual as needed. The Member Provider Policy & Procedure Manual and other information and materials provided by Blue Cross are proprietary and confidential and may constitute trade secrets of Blue Cross. CPT only copyright 2017 American Medical Association.

3 All rights 2017 2017 Ingenix, 2017 2017 Practice Management Information CorporationBlue Cross and Blue Shield of LouisianaMEMBER Provider (FACILITY) Policy & Procedure MANUAL87 Website/EmailCall/Fax'7,MailBlue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Box 98029, Baton Rouge, Louisiana 70898-9029 1-800-716-2299 Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures ManualDecember 20165 Quick Reference Guide to Important Addresses and Phone Numbers 8 Section 1: Network Participation 9 Participating Provider Agreements 9 Amendments to Provider Agreements 10 Member Provider Benefits 10 Allied Health Providers 11 Non-participating Providers 11 Credentialing Program 12 Credentialing Requirements for Freestanding Diagnostic Imaging Facilities 14 Locum Tenens 15 Medical Staff 15 Urgent Care Center Hours of Operation 15 Provider Directories 15 Health Care Consumer Billing and Disclosure Act 17 Section 2: Network Overview 18 Network Overviews 18 BlueCard Program 24 Consumer Directed Health Care 28 HMO of Louisiana Inc.

4 's Blue Advantage (HMO) Plan 31 Medicare Advantage Members from Other Blue Plans 31 Section 3: Member Engagement Tools 32 Section 4: Inpatient Acute Care Reimbursement 34 Overview 34 Charge Master Increase 35 Subcontracted Providers 36 Medical Staff 36 General Information 36 Diagnosis Code Specificity 37 Commercial Risk Adjustment 38 Payment Methodology Examples 38 MS-DRG Outlier Payment Examples 42 Payment Provision Worksheet (Per Diem)

5 43 Inpatient Billing Guidelines 44 Section 5: Outpatient Acute Care Reimbursement 47 Overview 47 Outpatient Procedure Services 47 Charge Master Increase 49 Billing Guidelines 50 Outpatient Procedure Services 50 Diagnostic and Theraputic Services 51 Drug Allowable Charge 53 Drug Screening Assays 53 Billing of Drug Eluting Intracoronary Stint 54 Other Outpatient Services 54

6 Outpatient Code Updates 54 Service Exempt from the Multiple Procedure Discount 55 Multiple Service Reduction for Diagnostic Imaging Services 56 Member Provider Policy and Procedure ManualTABLE OF CONTENTS6 Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures ManualDecember 2016 New Codes 56 Not Seperately Reimbursable Codes 57 Observation 57 Emergency Room 57 Pricing Flowchart for Outpatient Acute Care Reimbursement 58 Section 6: Additional Reimbursement Information 59 Other Facility Reimbursement Programs 59 Physician Reimbursement 59 Section 7: Claims Submission & Payment 61 Important Rules for All Claims Submissions 61 Overpayments 62 Federal Employee Program (FEP) Non-Network Claims-Direction of Payment 62 Claims Re-submission (Re-filing) 62 Adjustment and Void Claim Submission 62 Diagnosis/ Procedure coding 64 Procedure Codes and Guidelines -Professional & Certain Outpatient Services 65 Modifiers 65 Provider Access to iLinkBlue Medical coding Section 67 Serious Preventable Events and Present on Admission Indicators 67 National Provider Identifier (NPI) 71 Tax ID Numbers (TIN) 73 Reporting National Drug Code (NDC)

7 On Claims 73 Coordination of Benefits 74 Subrogation 74 Employment-related Injuries or Illness 75 Medicare Supplemental Claims 76 Nonparticipating Member Provider Benefits Payment Policy 78 Timely Filing and Refunds Process 79 Member Refunds 79 UB-04 Claim Form 80 CMS-1500 Health Insurance Claim Form 86 iLinkBlue 1500 Claim Electronic Entry Screen 92 Example Payment Register/Remittance Advice 97 Payment Register/Remittance Advice Explanation 98 Section 7A: Electronic Claims Submission & Payment 99 Electronic Data Interchange (EDI) 99 iLinkBlue Provider Suite 99 Electronic Payment Register/Remittance Advice 100 Electronic Funds Transfer (EFT) 101 EFT Application Guide 102 EFT Application Form 105 Section 8: Billing Guidelines 107 Ambulance 108 Anesthesia 115 Behavioral Health 124 Chiropractic and Therapy Services 134 Delivery of Pregnancy 138 Dialysis 140 Dietitian Billing Guidelines 141 Laboratory - Using Preferred Reference Labs 143 Sleep Study 147 Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures ManualDecember 20167 Home Sleep Study Services for Obstructive Sleep Apnea (OSA) 149 Home Health 150 Section 9.

8 Federal Employee Program 154 Standard Option 154 Basic Option 154 Cancer Screening 155 Provider Tips 155 Section 10: Provider Audits 156 Section 11: Medical Management 157 Overview 157 Utilization Review Organization 157 Authorization Process 157 Concurrent Review 159 Case Management 160 Retrospective Review 160 Medical Policy Inquiry 161 Direct Access 162 Services That Requiring Authorization Prior to Rendering Services 163 OGB Plan Services Requiring Authorization 164 Authorization for High-Tech Imaging Services 165 Authorization Penalties for Providers 166 Drug Authorizations 167 Quality Management Program 167 Step Therapy Program 168 Maternity Management Program - Healthy Blue Beginnings 169 Explanation of Admission and Recertification Request Form 170 Admission and Recertification Request Form 171 Section 12.

9 Medical Appeals 173 Standard Administrative Appeal 174 Standard Medical Appeal 175 Expedited Internal Medical Appeal 176 Expedited External Medical Appeal 177 Section 13: General Dispute Resolution & Arbitration Process 179 Section 14: MS-DRG Type of Service Listing 181 Section 15: Communicating with Blue Cross 196 Electronic Benefit Verification 196 Provider Services Voice Response Telephone System Call Center 196 Customer Service 197 Preadmission Authorization 197 Provider Network Administration 198 Provider Relations Services 198 Section 16: Definitions 199 Summary of Changes 2098 Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures ManualDecember 2016 Quick Reference Guide to IMPORTANT ADDRESSES AND PHONE NUMBERSP rovider Services Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc.

10 Offer an enhanced Interactive Voice Response (IVR) system that lets you and your office staff take care of many routine services by phone 24 hours a day, seven days a week. Call the customer service phone number on the back of your patient s Blue Cross ID card and enter your NPI number and the patient s Member number when prompted and select one of the following options: Benefits - Voice back of benefits - Fax back of benefits Claims - Voice back of claims status - Fax back of claims status Medical Management* - Status of authorization - Request new authorization*Medical Management requests are handled by transfer; not currently by Network Relations Questions: 1-800-716-2299 or (225) AddressesAll completed claim forms should be forwarded to the following addresses for processing: Blue Cross and Blue Shield of Louisiana Box 98029 Baton Rouge, LA 70898-9029 8',EDI 291-4334 BlueCard Eligibility Line1-800-676-BLUE (1-800-676-2583) Member BenefitsCall the number on the Member s ID & Abuse Hotline1-800-392-9249 Appeals and Grievances/ Provider Dispute ResolutionBlue Cross and Blue Shield of LouisianaAppeals and Grievance Box 98045 Baton Rouge, LA 70898-90451-800-376-7741 FEP claims should be mailed to.