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Provider Administration Manual - Health Insurance

Provider Administration ManualRevised June 2018 bluecross blueshield of tennessee Provider Administration Manual i TABLE OF CONTENTS I. INTRODUCTION A. bluecross blueshield of tennessee Statement of Purpose B. Descriptions of Networks C. Individual Product and Plan Options D. Health Insurance Portability and Accountability Act of 1996 (HIPAA) 1. Health Information Privacy Policies and Procedures 2. Protected Health Information-allowable disclosures under HIPAA E. General Information 1. Fraud and Abuse Hotline 2. Interpretation Services 3. Provider Communications 4. Pre-existing Condition II. bluecross blueshield OF tennessee QUICK REFERENCE TELEPHONE GUIDE III. HOW TO IDENTIFY A bluecross blueshield MEMBER A. Identifying a Member s ID Card B. Determining Eligibility C.

BlueCross BlueShield of Tennessee Provider Administration Manual ii VI. BILLING AND REIMBURSEMENT (cont’d) A. How to File a Claim (cont’d)

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Transcription of Provider Administration Manual - Health Insurance

1 Provider Administration ManualRevised June 2018 bluecross blueshield of tennessee Provider Administration Manual i TABLE OF CONTENTS I. INTRODUCTION A. bluecross blueshield of tennessee Statement of Purpose B. Descriptions of Networks C. Individual Product and Plan Options D. Health Insurance Portability and Accountability Act of 1996 (HIPAA) 1. Health Information Privacy Policies and Procedures 2. Protected Health Information-allowable disclosures under HIPAA E. General Information 1. Fraud and Abuse Hotline 2. Interpretation Services 3. Provider Communications 4. Pre-existing Condition II. bluecross blueshield OF tennessee QUICK REFERENCE TELEPHONE GUIDE III. HOW TO IDENTIFY A bluecross blueshield MEMBER A. Identifying a Member s ID Card B. Determining Eligibility C.

2 Member Fees IV. GROUP Health CARE BENEFITS A. Eligible Providers of Service B. Additional Services C. General Exclusions from Coverage V. MEMBER POLICY A. Introduction B. Member Access-To-Care C. Member Rights and Responsibilities D. Member Grievance Process E. Financial Responsibility for the Cost of Services VI. BILLING AND REIMBURSEMENT A. How to File a Claim 1. Filing Electronic Claims (Required Method) a. Provider Number/National Identifier (NPI) Number for Electronic Claims b. Electronic Data Interchange (EDI) c. Secure File Gateway (SFG) d. ANSI 837 (Version 5010) bluecross blueshield of tennessee Provider Administration Manual ii VI.

3 BILLING AND REIMBURSEMENT (cont d) A. How to File a Claim (cont d) 2. Filing Paper Claims 3. Tips for Completing CMS-1500 and CMS-1450 Claim Forms a. General Tips Whether Submitting OCR or Paper b. Billing Requirements for Faxed Paperwork (PWK) Attachments 4. CMS-1500 Health Insurance Claim Form a. CMS-1500 Form Field Descriptions b. Data Elements Required for Submitting CMS-1500 Claims 5. Completing CMS-1500 Claim Form a. General Instructions 1. Form Alignment 2. Entering All Dates b. Physical Claim Form Specifications c. CMS-1500 Specific d. Special CMS-1500 Claim Billing Guidelines Blocks 31 and 33 1. Physician 2. Health Care Professional 3. Medical Service Provider 6. Staff Supervision Requirements for Delegated Services a. Provider Categories/Billing and Supervision Requirements 1.

4 Licensed Providers Requiring Supervision and Retrospective Review 2. Licensed Physicians Requiring Minimal Supervision 3. Certified Providers Requiring Direct and Close Supervision 4. Clarification of Terms Used Within this Policy a. Autonomous Provider b. Supervision by Retrospective Review c. Minimal Supervision d. Direct and Close Supervision 7. Locum Tenens Policy 8. CMS-1450 Facility Claim Form a. CMS-1450 (UB04) Form Locators and Field Descriptions b. Revenue Code (FL42) c. HCPCS Codes/Rates (FL44) d. Service Units (FL46) e. Principal Diagnosis Code (FL67) f. Principal Procedure Code (FL74) g. Attending Physician (FL76) h. CMS-1450 Specific 9. Instructions for Returned Claims and Processed Claims needing Correction a. Incomplete Claims b. Corrected Bills 1. Corrected Electronic Claims (Required Method) 2.

5 ANSI-837P (Professional) and ANSI-837I (Institutional) 3. Method for Filing Corrected Paper Claims 10. Coordination of Benefits 11. Maintenance of Benefits bluecross blueshield of tennessee Provider Administration Manual iii VI. BILLING AND REIMBURSEMENT (cont d) 12. Right of Reimbursement and Recovery (Subrogation) 13. Balance Billing 14. Provider Overpayment Recovery Policy/Process a. Overpayment Notifications b. Automatic Overpayment Recovery c. Manual Overpayment Recovery 15. Electronic Funds Transfer 16. Federal Employees Plan (FEP) Claims Filing Guidelines B. General Billing and Reimbursement Guidelines 1. Medical Clinical Code Sets and Maintenance a. Current Dental Terminology (CDT) b. Current Procedural Terminology (CPT ) c. HealthCare Common Procedural Coding System (HCPCS) d. International Classification of Diseases (ICD) Coding 2.

6 Miscellaneous, Non-Specific and Not Otherwise Classified (NOC) Procedures/Services 3. Special Report 4. Code Edits 5. Modifiers a. Modifier 22 Unusual Procedural Services b. Modifier 25 c. Modifier 57 d. Modifier 59 and Other Specific Modifiers for Distinct Procedural Services e. Modifier 63 Reimbursement Guidelines for Procedures Performed on Infants Less than 4kg f. Modifier KX 6. Network MSM effective January 1, 2014 7. Qualitative Drug Screen Testing 8. Reimbursement Policy for Serious Reportable Adverse Events (Never Events) 9. Final Reimbursement 10. Policy for Quarterly Reimbursement Changes 11. Policy for Codes Priced on an Individual Consideration Basis C. Professional Claim Billing and Reimbursement Guidelines 1. Lesser Of Calculation 2. Guidelines for Resource Based Relative Value Scale (RBRVS) 3. Anesthesia Billing and Reimbursement Guidelines a.

7 Administration of Anesthesia b. Reimbursement Guidelines for Administration of Anesthesia 1. Basic Values 2. Time 3. Physical Status Unit Values 4. Time Units, Conversion Factors and Percentages 5. Medical Supervision of Anesthesia Services bluecross blueshield of tennessee Provider Administration Manual iv VI. BILLING AND REIMBURSEMENT (cont d) C. Professional Claim Billing and Reimbursement Guidelines (cont d) 3. Anesthesia Billing and Reimbursement Guidelines (cont d) c. Qualifying Circumstances d. Reimbursement Guidelines for Qualifying Circumstance e. Unusual Forms of Monitoring f. Reimbursement Guidelines for Unusual Forms of Monitoring Anesthesia g. Postoperative Pain Management Placement of Epidural h. Reimbursement Guidelines for Postoperative Pain Management- Placement of Epidural i. Postoperative Pain Management Daily Hospital Management of Epidural (continuous) or Subarachnoid (continuous) Drug Administration j.

8 Reimbursement Guidelines for Postoperative Pain Management Daily Hospital Management of Epidural (continuous) or Subarachnoid (continuous) Drug Administration 4. Obstetric Anesthesia 5. Reimbursement Guidelines for Administration of Regional or General Anesthesia Provided by a Surgeon 6. Reimbursement Policy for Moderate Conscious Sedation 7. Reimbursement Guidelines for Bundled Services Regardless of the Location of Service 8. Reimbursement Guidelines for Bundled Services when the Location of Service is the Practitioner s Office 9. Reimbursement Guidelines for Global Periods 10. Assistant-at-Surgery 11. Global, Professional and Technical Components for Radiology, Laboratory and Other Diagnostic Procedures 12. Reimbursement Guidelines for Bilateral Procedures 13. Reimbursement Guidelines for Multiple Procedures 14. Reimbursement Guidelines for Preoperative Management Only, Surgical Care Only, and Postoperative Management Only Services 15.

9 Reimbursement Guidelines for Procedures Performed by Two Surgeons 16. Reimbursement Guidelines for Screening Test for Visual Acuity 17. Reimbursement Guidelines for Visual Function Screening 18. OB/GYN Services 19. Reimbursement Guidelines for Independent Lab Services 20. Reimbursement Guidelines for Measurement Reporting Codes 21. Reimbursement Guidelines for STAT Services 22. Reimbursement Guidelines for Online Evaluation and Management 23. Guidelines for Evaluation and Management (E&M) New or Established Patient Determination 24. Billing Guidelines and Documentation Requirements for CPT Code 99211 bluecross blueshield of tennessee Provider Administration Manual v VI. BILLING AND REIMBURSEMENT (cont d) C. Professional Claim Billing and Reimbursement Guidelines (cont d) 25. Genetic Counseling Services Billing Guidelines 26. Chiropractor Billing and Reimbursement Guidelines (Does not apply to MedAdvantage) 27.

10 Injections and Immunizations a. Reimbursement Guidelines for Vaccines and Toxoids b. Reimbursement Guidelines for Infusion Therapy, Immune Globulin, Nebulizer, Chemotherapy and Other injectable Drugs c. Preventive Vaccines Administered by a Pharmacist d. Specialty Pharmacy Medications e. Compound Drugs f. Compounding Services g. Reimbursement and Billing Guidelines for Radiopharmaceuticals and Contrast Materials h. Reimbursement Guidelines for Non-Injectable Medications when the Location of Service is the Practitioner s Office i. Reimbursement Guidelines for Self-Administered Prescription Medications Dispensed and Submitted by a Licensed Pharmacist j. 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 k. Reimbursement Guidelines for Medications Not Requiring a Prescription from a Licensed Pharmacist Regardless of the Location of Service 28.


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