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H
Blue Cross of Northeastern Pennsylvania,
First Priority Health and
Highmark Blue Shield Updates
January 7, 2011 1
Blue Cross of Northeastern
Pennsylvania Updates
• BlueCard Satisfaction Survey
• Results: 80% - Scores have increased in the past year.
• Phone Surveys begin in April 2006.
• Contact your Provider Relations Consultant to address areas of
improvement.
• Medicare (MC) Cross Over Initiative – More claims will be
automatically submitted to the secondary insurance.
• MC Primary/Blue Plan Secondary
• Review MC remittance advise (RA)
• If RA indicates claim crossed over, no need to submit claim to BCNEPA.
• If RA indicates claim did not cross over, submit claim to BCNEPA with MC
RA.
• Review March 2006 BCNEPA Provider Bulletin for additional information.
January 7, 2011 2
Blue Cross of Northeastern
Pennsylvania Updates Con’t
• BCNEPA Changes Product Names, Offers
Same Quality Service
– Former Name New BlueCare Name
Group Plans
Access Care II BlueCare PPO
Comprehensive Major Medical BlueCare Comprehensive
Traditional BlueCare Traditional
65-Special BlueCare Senior
January 7, 2011 3
Blue Cross of Northeastern
Pennsylvania Updates Con’t
• BCNEPA Changes Product Names, Offers
Same Quality Service
– Former Name New BlueCare Name
Individual Plans
Major Medical BlueCare Major Medical
Non-Group Cooperative BlueCare Cooperative
Security 65 BlueCare Security
Student BlueCare Student
January 7, 2011 4
Blue Cross of Northeastern
Pennsylvania Updates Con’t
• BCNEPA Reconsideration Form
– Used when requesting BCNEPA Claims Departments
(BlueCare Traditional, FEP, Blue Care PPO and
ITS/BlueCard) to reconsider payment for full or partially
denied claims.
– Does not replace the “Blue Cross Adjustment Form”.
– How to get BCNEPA Reconsideration Forms:
» Completing the yellow BCNEPA Provider Order
Form (#11-B360F) and requesting inventory #11-
B084F;
» BCNEPA NaviNet or via secure access, Provider
Relations section, then Forms section.
January 7, 2011 5
First Priority Health Updates
• First Priority Health Changes Product Names,
Offers Same Quality Service
– Former Name New BlueCare Name
Group Plans
First Priority Health BlueCare HMO
First Priority Health Plus BlueCare POS
Individual Plans
First Priority Health Individual BlueCare HMO Individual
Conversion Conversion
January 7, 2011 6
First Priority Health Updates Con’t
• FPH MRI Precertification Requirements
– Updated MRI Precertification List to include MRI of the breast
– FPH Precertification Department Phone #: 1-800-962-5353
– FPH Precertification Department Fax #: 570-200-6799 (or via NaviNet)
– For details, review the February 2006 Provider Bulletin.
• Health Improvement Posters
– Delivered to PCP and OB/GYN offices in 3rd & 4th quarter 2005.
– Contact your Provider Relations Consultant for additional posters, and/or health
improvement brochures.
• Surveys - Reminder
– Outpatient Radiology (February)
– Outpatient Lab (July)
– Provider Satisfaction (October)
January 7, 2011 7
First Priority Health Updates Con’t
• Provider Data Review (PDR)
– Purpose: to maintain current information for the FPH claims system and
provider directories.
– Mailed to primary care physicians, specialists and facilities annually in
in December.
– Make changes on PDR form.
– Be certain to review and update all pages of the form.
– If you have not received this form, contact the Provider System Support
Department at 1-800-451-4447.
– Fax completed form to the Provider System Support Department at
570-200-6880.
January 7, 2011 8
Highmark Blue Shield Updates Con’t
• HMBS website: www.highmarkblueshield.com
– Lower right corner – “Providers Resource Center”
– Publications & Mailings – Clinical Views, PRN, Patient News,
& Special Bulletins & Mailings;
– Highmark Radiology Management Program;
– Administrative Reference Materials;
– Clinical Reference Materials;
– BlueCard Information Center;
– Provider FAQs;
– Medical Policy;
– Pharmacy/Formulary Information;
– HIPAA;
– Electronic Data Interchange (EDI) Services;
– Health Care Directory;
– Helpful Links.
January 7, 2011 9
Highmark Blue Shield Updates Con’t
• Credentialing and Recredentialing Functions
– Effective February 1, 2006, the BCNEPA Quality Management
Department began providing all HMBS
credentialing/recredentialing functions for Participating and
PremierBlue Shield providers.
– Do not use on-line applications via the HMBS website.
– Currently using the PA Standard Application.
– PA Standard applications are not found on the BCNEPA
Provider Center.
– Contact the Provider Relations Department at 1-800-451-4447
for a HMBS application.
– Credentialing questions can be directed to Diane Jones,
BCNEPA Credentialing Manager at 570-200-4396, or via fax at
570-200-6890.
January 7, 2011 10
Highmark Blue Shield Updates Con’t
• The following resources have not changed due to the new Joint Operating
Agreement (JOA)…
– HBS-Hosted NaviNet - (Internet-based service for enrollment and
benefits information, claim status and program allowances).
– OASIS - (for eligibility, benefits, and status of claims): 1-800-462-
7474.
– InfoFax – (for claim status and enrollment): 1-800-891-1856.
– Grievance or Appeals – Upon written consent from the member,
Participating and Premier BlueShield providers may file a grievance or
appeal submitted in writing to:
» Complaint/Grievance Department
P.O. Box 890179
Camp Hill, PA 17089-0179
» Or via telephone: 1-877-865-5847 (for expedited appeals only)
January 7, 2011 11
Highmark Blue Shield Updates Con’t
• The following resources have not changed due to the new Joint
Operating Agreement (JOA)…
– Provider Claims Appeals – Participating and PremierBlue
Shield Provider Claims Appeals should be sent in writing to:
» Provider Claims Appeals
P.O. Box 890179
Camp Hill, PA 17089-0179
– Predeterminations – Requests from Participating and Premier
BlueShield providers for predeterminations for medical
necessity should be forwarded in writing to:
» Pre-Authorization
P.O. Box 890041
Camp Hill, PA 17089-0041
January 7, 2011 12
Highmark Blue Shield Updates Con’t
• The following resources have not changed due to the new Joint
Operating Agreement (JOA)…
– Claims Submission: No change in submission processes for
electronic or hard copy claims.
– NOTE: Participating ambulance, DME, home infusion and
P&O providers claims for FEP and BlueCard members only
should still be directed to Highmark BlueShield for processing
via electronic submission or hard copy to the following address:
» Highmark Blue Shield
P.O. Box 890062
Camp Hill, PA 17089-0062
January 7, 2011 13
Highmark Blue Shield Updates Con’t
• Independence Blue Cross (IBC) Issues
– HMBS no longer processes claims for IBC Personal Choice and
Personal Choice 65 members. In addition, HMBS no longer
processed claims for AmeriHealth PPO members. IBC, which is
located in southeastern PA, now manages the processing of
these claims.
– Please review the HMBS February 2006, and March 2006
Special Bulletin located on the HMBS website:
www.highmarkblueshield.com for specific details regarding
important electronic and paper claim submission information, as
well as the additional IBC alpha prefixes.
– For questions concerning claim related issues, please call IBC
directly at 1-800-332-2566.
– Electronic claims issues – Call IBC’s eBusiness Service Desk at:
» (215) 241-2305 or email: claims.edi-admin@ibx.com
January 7, 2011 14
Highmark Blue Shield Updates Con’t
• Federal Employee Program (FEP):
– Two Options: Standard and Basic
Standard ID Card Basic ID Card
January 7, 2011 15
Highmark Blue Shield Updates Con’t
• FEP Standard Option:
– Now has chiropractic benefits, which differ from Basic Option. All FEP
benefit questions, should be directed to 1-866-763-3608.
• BlueCard – Top Errors on BlueCard Host Claims Submission:
– Alpha prefix not reported
– Alpha prefix typed incorrectly
– Coverage cancelled
– Service dates before effective date of coverage
– Diagnosis code not to the highest level of specificity
– No billing and performing provider ID numbers reported
– No place of service reported
– Procedure code not valid or was deleted with new year HCPCS
implementation
– Provider sent claim to the wrong plan
– Claim not filed “timely” to Highmark
– Duplicate Services
January 7, 2011 16
Highmark Blue Shield Updates Con’t
• 2006 Reimbursement Initiative:
– HMBS is currently reviewing its rates.
– Updates will be available in July 2006.
– Additional information will be printed in a upcoming PRN
publication and/or Special Bulletin.
• 1099 Reporting:
– Historically, incorrect reporting of individual provider as the
billing provider on claims.
– Ensure use of correct billing provider number on all claims.
– Beginning with the next issue of 1099s for 2006 data, Highmark
Blue Shield will no longer change 1099s.
January 7, 2011 17
Highmark Blue Shield Updates Con’t
• Electronic Claims Submission:
– Advantages…
» Faster payment
» Reduced office expense
» Electronic edits – Immediate error
correction/resubmission
» Immediate confirmation
» Timely validation and payment notices
– To Get Started…
» Contact Highmark EDI at 1-800-992-0246
» Or, to complete the forms online, access:
a) www.highmarkblueshield.com
b) Select the Provider Resource Center then,
EDI services
January 7, 2011 18
General Information
• Provider Bulletins
– Important Notifications, i.e. billing updates, medical policy updates, etc.
– Provider Relations Consultants’ phone number and email address located on last
page of each bulletin.
– Provider Services phone numbers and fax numbers for all lines of business are
located on the last page of every monthly bulletin.
• Unique Member Identifier (UMI)
– All Blue Plans have successfully completed the UMI process and have replaced
Social Security numbers on ID cards to ensure member privacy.
– New identifier – begins with a 3 character alpha prefix.
• BCNEPA/FPH Billing Manual
– BCNEPA Provider Center via NaviNet or Secure Access.
– Providers with no IA should have received CD version.
– All BCNEPA and FPH manuals are available on the Provider Center via
BCNEPA NaviNet, or secure access.
January 7, 2011 19
General Information
• BCNEPA/FPH Acute Rehabilitation
– New guidelines effective May 1, 2006.
– Patients must meet specific diagnostic criteria along with
meeting all additional criteria.
– Diagnosis of hip or knee replacement will require medical
director review.
– Rehabilitation Risk Scoring Sheet for total joint replacement
will no longer be used.
– For additional details, please reference the April 2006 Provider
Bulletin.
January 7, 2011 20
General Information
THANK YOU
January 7, 2011 21
