Provider Types & Pricing Terms by l9xX2J

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									     05
                   Healthcare Professionals

Objectives
After reading this chapter the learner will be able to:

1. Recognize different types of healthcare professionals
2. Identify a healthcare professional’s specialty using the tax ID number
3. Determine a healthcare professional’s contracting status using the provider indicator
   and IT pop-up
4.


Overview
A healthcare professional is a physician, freestanding diagnostic laboratory, imaging
facility, durable medical equipment vendor, or ambulance that is appropriately licensed
to provide care.

A physician is not only defined as a medical doctor (M.D.) or doctor of osteopathy
(D.O.), but also as any of the following:

       Dentist (D.D.S.)                              Marriage, Family and Child
       Optometrist (O.D.)                             Counselor (M.F.C.C.), or
       Dispensing Optician                            Marriage, Family, Child Therapist
       Podiatrist or Chiropodist (D.P.M.              (M.F.C.T.)
        or D.S.C.)                                    Physical Therapist (P.T. or
       Psychologist                                   R.P.T.)
       Chiropractor (D.C.)                           Speech Pathologist
       Certified Registered Nurse                    Audiologist
        Anesthetist (CRNA)                            An Occupational Therapist
       Acupuncturist (license begins                  (O.T.R.)
        with AC)                                      Respiratory Therapist
       Clinical Social Worker (C.S.W. or             Psychiatric Mental Health Nurse
        L.C.S.W.)                                     Physician Assistant
                                                      Certified Nurse Midwife
                                                      Registered Nurse Practitioner




OPD Claims Operations Performance Department   1
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
Contracting Status
The procedures that healthcare professionals can bill are listed in the current CPT
(Current Procedural Terminology) and HCPCS (Health Care Financing Common
Procedure Coding System) books. Anthem Blue Cross receives allowable amounts
for procedures from the HOST Plan. There are three types of contracts but paid in
four ways. PPO (PN), Traditional paid as PPO (BN), Traditional paid at Non-
participating (DN) and Non-participating (DN).

PPO Healthcare Professionals (also known as “Par”) have a Prudent Buyer
Participating Agreement in effect with the HOST Plan at the time services are rendered,
meaning they sign a contract agreeing to accept the negotiated rate as payment in full.
Members benefit greatly by utilizing participating healthcare professionals, because the
rates can be significantly lower than the rates typically billed in the medical community

Non-participating healthcare professionals are those who have been offered, but
have chosen not to accept the Prudent Buyer agreement, or who have not been
selected to participate. Since the healthcare professional has no contract, the member
can be billed for any amount in excess of the customary and reasonable amount.

Limited healthcare professionals are those who are either not offered a contract the
network of participating professionals is still open, or in circumstances where members
do not have adequate access to participating healthcare professionals.

Claims for limited healthcare professionals are paid at the same percentage at which a
participating healthcare professional would be paid.

      Listed below are examples of limited healthcare professionals:
       Blood banks
       Optometrists
       Dispensing opticians
       Respiratory therapists

See member’s EOC for further limited providers.




OPD Claims Operations Performance Department   2
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
PPO, Traditional and Non-Par Providers
BlueCard members are expected to seek out PPO providers when circumstances are
elective. It is not enough for them to ask only if they are “participating” with Blue Cross
or Blue Shield.

Services from Traditional only and Non-par providers will be paid at Non-participating
levels, unless the HOST Plan indicates there were no PPO providers available.
Remember that only a portion of the amount a Non-par provider charges for services
will be paid by Anthem Blue Cross. The member will be responsible for any billed
charges over the Customary and Reasonable amount as well as their coinsurance.




OPD Claims Operations Performance Department   3
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
BlueCard claims come through the ITS system indicating if the provider is PPO,
Traditional or Non-par with the HOST Plan. This information is found on the IT pop-up
and on the IMAGE processing screen.

Below is an example of a claim for a PPO provider.
Screen Shot 1: Example of the IMAGE processing screen for a PPO provider
   GNCIMGQ                 WELLPOINT GROUP SYSTEM            P 08/25/03 22:55:16    1
     ZGSOSB9    VTC00114 ***ADJUDICATED*** - INQUIRY                        VERSION 000

    OP ____ Q 217099 PA DCN 0320148XXXX ID XXXXXXXXX GP XXXXNG               CPT CNT B475D
    MC 20 PAT SUZANNE SEX F AUTH Y_ WC N REF N SP _ PMG ____ ______ A# ______ IZ _
    COB N _ M/CARE N _ U/R# 7094285501 PROCD ____ ______ _               ALLOW ______16845
    FROM ______ THRU ______ ADM ______ TRT/AUTH CD __________________ COB % ___
    03 OF 03 DX1-5 V288__ V2349_ ______ ______ ______ TEXT N ERS Y MEM BN PRV PN
       DATE    PT PROC/MD DX         CHARGE        SVC UO DED % S/L E HC C&R CR900000 L/R _
    01 070103 11 36415__ 12___ _______2000 SRG 001 _ ___ _ W_ __ WRTOFF ______55155
    02 070103 11 76817__ 12___ ______35000 DXL 001 _ ___ _ W_ __ DEDUCT ___________
    03 070103 11 76801__ 12___ ______35000 DXL 001 _ ___ _ W_ __ CO-PAY ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ RJCTED ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ B-PAY ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ MM PAY ______16845
    LN 01 PEND ______ RTE ______ Y PY __ ACT P10000 _ EXT _              TOTCHG ______72000
    TY WRITEOFF      TY DEDUCT TY OTHER              UO TY CO-PAY      TY REJ/OTH      UO
        “PN” indicates this provider is ___________ __ __ ___________ __ ___________ __
    __ ___________ __ _______ __ PPO. PPO providers have
        negotiated special rates with ___________ __ __ ___________ __ ___________ __
    __ ___________ __ _______ __ local Blue Cross and Blue Shield
        plans. These rates are exclusive to patients __ __ ___________ __ ___________ __
    __ ___________ __ _______ __ ___________ identified as
                                                       PAY ___________ TY __ UO __ MORE _
        members of PPO groups.
      HP IT                                           NOA __________ N-DCN ___________
      PF01=HELP     PF02=ENTRY PF03=RETURN PF04=EOBDTL PF05=EOBSUM PF06=SUMCLM
      PF07=PREV     PF08=NEXT      PF09=VIEW1 PF10=VIEW2 PF11=COVIND PF12=AUDV

Screen Shot 2: Example of the IT pop-up for a PPO provider
   GNCITSI                WELLPOINT GROUP SYSTEM        P 08/25/03 22:55:41    1
     ZGSOSB9                  ITS HOME DISPLAY                         VERSION
            ID: CPT XXX XX XXXX    MC: 20    DCN #: 03201 48 XXXX    LOG: _

     ORIG SCCF #: 3032003199XXXX00              ADJ SCCF #: _________________
     CLM TYPE: 20 PROF       SF ALPHA PRFX: CPT            SF RECEIPT DATE: 07/17/2003
     PPO NTWK AVBL: Y        PPO PROV AVBL: Y              HOST PROV IND:      P
     PAY IND: 2 HOST PAYS PROVIDER                                          835/EFT: _
     NMS PRVDR SPCLTY: 375 ITS PRVDR SPCLTY: 16              MPPQ~ASGN: _ ~UNASGN: _
     SF MSG CODES:    _____ _____ _____ _____ _____                    PRIMACY IND: _
     PRICE MTD: 40       RULES:     009 ______                         COB CALC MTD: ___
     FEES: ACCESS: _____________            ADMIN: _____________ SPPQC IND: _
            CFA:     $0.29                  TXN:      $0.10       CARVEOUT: N DAYS: ___
    ------------------------------------------------------------------------------
                             The IT pop-up indicates a PPO network
                                HPA AUTOMATION were PPO
                             was available, there RESULTS
     HPA IND: 2 AUTOMATED HPA            NONELIG RSN: __ _________________________
                             providers for this specialty available and
     DF DATE: 07/22/2003     HPA REJECT RSN: ____ ______________________________
                             the provider was PPO with the HOST _____
     TAX AMT: _____________ HPA/UPF ERRORS: _____           _____
     ADJUSTMENTS: FUNC CDE: Plan. _     ____________________              STRM ADJ: N
                   REASON:        ___ ___________________________________
                   XREF SCCF:     _________________

      PF01=HELP                    PF03=RETURN




OPD Claims Operations Performance Department     4
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
Below is an example of a claim for a Traditional provider.

Screen Shot 3: Example of the IMAGE processing screen for a Traditional provider
   GNCIMGQ                 WELLPOINT GROUP SYSTEM                 P 08/25/03 21:52:25    1
     ZGSOSB9    VTC00114 DETAIL PROCESS - PROF INQUIRY                           VERSION 000

    OP ____ Q 217099 PA DCN 0321548XXXX ID XXXXXXXXX GP XXXXFC                      BEV CNT H561D
    MC 30 PAT JOSEPH SEX M AUTH Y WC N REF N SP _ PMG ____ ______ A# ______ IZ _
    04 OF 04 DX1-5 496___ ______ ______ ______ ______ ERS Y                     MEM BN     PRV BN
        DATE     PT PROC/MD DX          CHARGE       SVC UO DED % S/L E C&R TPA10000 L/R _
    01 070903 12 J7619KO 1____ ______16500 PHO 300 N 100 N W WRITEOFF ___________
    02 070903 12 A7003NU 1____ ________600 SUP 002 N 100 N W DEDUCT                    ___________
    03 070903 12 A7004NU 1____ ________330 SUP 002 N 100 N W CO-PAY                    ___________
    04 070903 12 E0590__ 1____ ________575 HHC 001 N 100 N W REJECTED ________575
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ _ B-PAY                     ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ _ MM PAY                   ______17430
    LN 01 PEND ______ RTE ______ Y PY 40 ACT P10000 _ EXT _                TOT CHRG ______18005
        TY indicates TY DEDUCT
    LN“BN” WRITEOFFthis provider is Traditional.
                                        TY OTHER     TY CO-PAY    TY REJ/OTH PAY            TY HC
        __ ________ __ ________ who have
    01Traditional providers are those __ ________ __ ________ __ ________ ___16500 MP __
    02contracts with their local Blue Cross or Blue __ ________ __ ________ _____600 MP __
        __ ________ __ ________ __ ________
        __ ________ __ ________ __ ________ __ ________ __ ________ _____330 MP __
    03Shield plans, but have not accepted the
                                                              “BN” if _____575 ________ __ __
        __ negotiated schedules, which ________ __ ________ EX no PPO providers
    04PPO ________ __ ________ __ are
        __ ________ __ ________ __                           available, “DN” if PPO
    __significantly better than traditional ________ __ ________ __ ________ ________ __ __
        __ ________ __ ________ __ ________ __ ________ __ ________ ________ __ __
    __schedules                                              providers were available.
      HP IT                                             NOA __________ N-DCN ___________ C _
    108 MRU-ROUTE PAPER                          GU1 VAU HP1
      PF01=HELP       PF02=ENTRY PF03=RETURN PF04=EOBDTL PF05=EOBSUM PF06=SUMCLM


Screen Shot 4: Example of the IT pop-up for a Traditional provider
   GNCITSI                WELLPOINT GROUP SYSTEM        P 08/25/03 21:57:02    1
     ZGSOSB9                  ITS HOME DISPLAY                         VERSION
            ID: BEV XXX XX XXXX    MC: 30    DCN #: 03215 48 XXXX    LOG: _

     ORIG SCCF #: 01020032130245300                ADJ SCCF #: _________________
     CLM TYPE: 20 PROF        SF ALPHA PRFX: BEV           SF RECEIPT DATE: 07/23/2003
     PPO NTWK AVBL: Y         PPO PROV AVBL: N             HOST PROV IND:         Y
     PAY IND: 2 HOST PAYS PROVIDER                                             835/EFT: _
     NMS PRVDR SPCLTY: V04 ITS PRVDR SPCLTY: CN                MPPQ~ASGN: _ ~UNASGN: _
     SF MSG CODES:    _____ _____ _____ _____ _____                      PRIMACY IND: _
     PRICE MTD: 41       RULES:       009 ______                         COB CALC MTD: ___
     FEES: ACCESS: _____________              ADMIN: _____________ SPPQC IND: _
            CFA:     $0.29                    TXN:      $0.10       CARVEOUT: N DAYS: ___
    ------------------------------------------------------------------------------
                            The IT pop-up indicates a PPO network was
                                HPA AUTOMATION RESULTS
                            available, there were no PPO providers for
     HPA IND: 1 NOT ELIGIBLE               NONELIG RSN: TC NON-ELIG TYPE CODE
     DF DATE: 08/05/2003
                                                    provider is Par
                            this specialty and the____ ______________________________
                              HPA REJECT RSN:
                                          with the _____
                            (traditional)ERRORS: HOST Plan. This claim
     TAX AMT: _____________ HPA/UPF                          _____      _____
     ADJUSTMENTS: FUNC CDE: would _ pay at the highest level of benefits. If STRM ADJ: N
                                          ____________________
                   REASON: there were PPO providers available for this
                                    ___ ___________________________________
                   XREF SCCF:       _________________
                            specialty, we would pay the claim at the
                               lower level of benefits.
      PF01=HELP                    PF03=RETURN




OPD Claims Operations Performance Department        5
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
Below is an example of a claim for a Non-par provider. This claim is an ECRP claim as
indicated by the GU3 edit

Screen Shot 5: Example of the IMAGE processing screen for a Non-par provider
   GNCIMGQ                   WELLPOINT GROUP SYSTEM                 P 08/25/03 22:26:53    1
     ZGSOSB9    VTC00114     SUMMARY PROCESS - INQUIRY                             VERSION 000

    OP ____ Q 217099 PA DCN 0322529XXXX ID XXXXXXXXX GP XXXXNG                ___ CNT B475D
    MC 20 PAT SUZANNE SEX F AUTH X_ WC N REF N SP _ PMG ____ ______ A# ______ IZ _
    COB N _ M/CARE N _ U/R# 339966                PROCD ____ ______ _     ALLOW _______6000
    FROM ______ THRU ______ ADM ______ TRT/AUTH CD __________________ COB % ___
    01 OF 01 DX1-5 V28___ ______ ______ ______ ______ TEXT N ERS Y MEM BN PRV DN
       DATE   PT PROC/MD DX        CHARGE          SVC UO DED % S/L E HC C&R CR900000 L/R _
    01 080203 81 82106__ 1____ _______6000 DXL 001 _ ___ _ 3_ __ WRTOFF ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ DEDUCT ___________
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ CO-PAY _______1200
    __ ______ __ _______ _____ ___________ ___ ___ _ ___ _ __ __ RJCTED ___________
    __ ______ __ “NN” indicates this provider is Non-par. Non-par _ __ __ B-PAY ___________
                  _______ _____ ___________ ___ ___ _ ___
                  _______ _____ ___________ ___ ___ _
    __ ______ __ providers do not have a PPO agreement with___ _ __ __ MM PAY _______4800
                 Anthem Blue Cross Y with the Blue Cross _ EXT
    LN 01 PEND ______ RTE ______ or PY __ ACT P10000 and/or _             TOTCHG _______6000
                    TY DEDUCT in OTHER               UO TY CO-PAY
    TY WRITEOFF Blue Shield plan TY effect at the time services are     TY REJ/OTH     UO
    __ ___________ __ _______ __ ___________ __ __ ___________ __ ___________ __
                 rendered.
    __ ___________ __ _______ __ ___________ __ __ ___________ __ ___________ __
    __ ___________ __ _______ __ ___________ __ __ ___________ __ ___________ __
                                                        PAY ___________ TY __ UO __ MORE _
      HP IT                                           NOA __________ N-DCN ___________
    GU3
      PF01=HELP    PF02=ENTRY PF03=RETURN PF04=EOBDTL PF05=EOBSUM PF06=SUMC


Screen Shot 6: Example of the IT pop-up for a Non-par provider
   GNCITSI                WELLPOINT GROUP SYSTEM        P 08/25/03 22:47:36    1
     ZGSOSB9                  ITS HOME DISPLAY                         VERSION
            ID: ___ XXX XX XXXX    MC: 20    DCN #: 03225 29 XXXX    LOG: _

     ORIG SCCF #: 30320032240479400               ADJ SCCF #: _________________
     CLM TYPE: 20 PROF       SF ALPHA PRFX: ___            SF RECEIPT DATE: 08/11/2003
     PPO NTWK AVBL: Y        PPO PROV AVBL: Y              HOST PROV IND:       N
     PAY IND: 3 HOME PAYS SUBSCRIBER OR SPECIAL PAYEE                        835/EFT: _
     NMS PRVDR SPCLTY: L02 ITS PRVDR SPCLTY: CB              MPPQ~ASGN: _ ~UNASGN: _
     SF MSG CODES:    _____ _____ _____ _____ _____                     PRIMACY IND: _
     PRICE MTD: 01       RULES: ______ ______                           COB CALC MTD: ___
     FEES: ACCESS: _____________            ADMIN: _____________ SPPQC IND: _
            CFA:    _______                 TXN:     _______      CARVEOUT: N DAYS: ___
    ------------------------------------------------------------------------------
                               HPA AUTOMATION RESULTS
     HPA IND: _ ____________________ NONELIG RSN:a __ _________________________
                               The IT pop-up indicates PPO network
     DF DATE: __________     HPA REJECT RSN: ____ ______________________________
                               was available, there were PPO
                               providers for this _____     _____
     TAX AMT: _____________ HPA/UPF ERRORS: specialty and the _____
     ADJUSTMENTS: FUNC CDE:       _     ____________________               STRM ADJ: N
                               provider is Non-par (traditional) with the
                   REASON:        ___ ___________________________________
                   XREF SCCF: HOST Plan. We will process this claim
                                  _________________
                                  at the lower level of benefits. Since this
      PF01=HELP                   is an ECRP claim, normal processing
                                   PF03=RETURN
                                  applies.




OPD Claims Operations Performance Department       6
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
Healthcare Professional Specialties
An important factor in determining contract benefits is knowing what type of services a
professional is billing. Knowing the healthcare professional’s specialty is very helpful in
determining what type of service is being rendered. Healthcare professionals are primarily
identified by their federal tax ID number (also known as EIN or employer identification
number). From a live claim, the tax ID number can be found on PAC View 1, as shown in
Figure 3.1.

Screen Shot 7
   GNCPACP                   WELLPOINT GROUP SYSTEM              P 10/17/03 10:11:12    1
     ZGSOSB9     VTC02587       PAC VIEW 1 PROFESSIONAL                         VERSION 001

    OP 3880 LOG _ Q 38PC00 PA DCN 03278 87 XXXX        XXX XX XXXX GRP 165099M003 IDO
                                                       ID
                                                                    ADJ N CONT J174F
    SUB   JOHN     MI L LAST SMITH                       WC N REF N        INJ ______
    ADR   4470 HARRISON RD         CTY KENOSHA       ST WI ZIP 53142 0000 ILL ______
    C/O   ________________________ AUTH Y CNSL ______ ATTACH __ RECDT 100503
    DX1   2774   DX2 ______ DX3 ______ DX4 ______ DX5 ______ RT-OV __ ELIG OV _ SP _
    A/R   _ IZ _    PMG/IPA ____ ______ AUTH# ______                   MR# __________
    ADD   N NC/ELIG _ COB N TEXT N SPAYEE _ MRU N ERS Y           LPPDTE ______

    TAX ID 391480198   PROV ACL SERVICES INC            L ___ PZ 53227 0901
    ADDR 8901 W LINCOLN AVE         CTY WEST ALLIS     ST WI ZIP 53227 0901
    PROV LIC NO ___ ________ PROV 2ND NAME ACL SERVICES INC
                                        C/O _________________________

      HP IT

                ACT ______ _ C _    PEND ______   RTE ______ Y     EXT _   N-DCN ___________

    GU1
      PF01=HELP      PF02=ITSUPD PF03=REFERL PF04=COVIND PF05=VIEW2 PF06=IMAGE
                                 PF09=ACCUMS PF10=BENCDE PF11=CLMHST PF12=HIQMENU




OPD Claims Operations Performance Department      7
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012
By placing the cursor on the tax ID and hitting F1, specific information regarding the
healthcare professional is displayed as shown in Figure 3.2

Screen Shot 8
   HIQPVPQ                        CORPORATE SYSTEMS          P   10/17/03 10:12:37
    ZGSOSB9     VTC02587     PROFESSIONAL PROVIDER INQUIRY                   VERSION 001

    TAX ID: 391480198 CANCEL CDE/DTE: 00 - 99/99/99 BH DEL: N LST UPD: 03/25/98
    BUS NAME: BAYSHORE CLINICAL LABORATORIES
     TX SPEC: L02 - INDEPENDENT LAB XRF TX: _________ AUD DTES: ________ - ________
    =============== CONTRACT DATA (BASED ON INPUT SERVICE DATES) =================
         PRODUCT              EFF DATE END DATE CANCEL CDE/RSN    G/I ACP LAST UPD
    BCH2 BEECH STREET - PROF 01/01/98 99/99/99 00-STILL ACTIVE     _   _ 11/12/99
    ____ ____________________ ________ ________ _________________ _    _ ________
    ____ ____________________ ________ ________ _________________ _    _ ________
    ____ ____________________ ________ ________ _________________ _    _ ________
    ____ ____________________ ________ ________ _________________ _    _ ________
    ____ ____________________ ________ ________ _________________ _    _ ________
    ____ ____________________ ________ ________ _________________ _    _ ________
    =============== LICENSED PROFESSIONALS FOR THIS TAX ID ( 0000 ) =============
    LICENSE NO: ___________    LAST NAME: ______________________________
    UPIN NO:     ______       FIRST NAME: _____________        MI: _    TITLE: ____
    SPECIALTIES: ___ - ____________________       CANCEL CODE/DATE: __ - ________
                 ___ - ____________________ ON AUDIT DATES: ________ - ________
    NEXT TRAN:             NEXT KEY: GNCPACP         SVC DATES: WELLPOIN   ZGSOSB
    PF1:RNTNETWK PF2:PROFADDR PF3:RETURN PF4:LICXREF PF5: SYSRETRN PF6:CORPMENU
    PF7:PREVLIC PF8:NEXTLIC PF9:CNTRCTS                   PF11:WITHHOLD PF12:DETL
    NO LICENSE RECORDS FOUND FOR THIS TAX ID.




OPD Claims Operations Performance Department   8
Professional Claims Processing Module 5
Created: 1/30/03 Revised 2/9/2012

								
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