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.

2 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. 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.

3 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.

4 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.

5 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. 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.

6 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.

7 Corrected Electronic Claims (Required Method) 2. 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.

8 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. 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.

9 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.

10 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.