Home

2014 Provider Office Administrative Manual

Contents

1. Kal GI South Carolina www SouthCarolinaBlues com 2014 BlueCross BlueShield of South Carolina PROVIDER OFFICE ADMINISTRATIVE MANUAL South Carolina Introduction BlueCross BlueShield of South Carolina is committed to providing quality service education and problem resolution to the health care community This Administrative Office Manual for Providers is part of that commitment We developed this manual to guide you through claim filing and to help you deal more effectively with our company We have put great effort into making sure the information in these pages is accurate If there is any conflict between the contents of this manual and a contract or membere certificate the contract or certificate will prevail Likewise if a conflict exists between the contents of this manual and a provider s contract with BlueCross the contract will prevail We will make annual revisions and updates to this manual We will also update provider information in the Education Center of our website www SouthCarolinaBlues com as needed Please send all suggestions for enhancements to this manual to Provider Relations and Education Department BlueCross BlueShield of South Carolina AX 624 I 20 at Alpine Road Columbia SC 29219 Provider Education bcbssc com The information in this manual is only general benefit information and does not guarantee payment Benefits are always subject to the terms and limitations of the p
2. South Carolina Electronic Remittance Advice ERA 835 and Electronic Funds Transfer EFT Providers with electronic file transfer capabilities can choose to receive the 835 ERA containing their Provider Payment Registers Once you download the remittance files at your office you can upload the files into an automated posting system This eliminates a number of manual procedures EFT deposits payments directly into your bank accounts allowing you to receive funds before BlueCross mails checks You can request ERA and EFT together or separately They are independent of each other Complete the ERA Addendum found on www HIPAACriticalCenter com The EFT form is available on www sSouthCarolinaBlues com Remittance advices are also available in My Insurance Manager EDI Help For all questions concerning the electronic interchange of health care data contact the EDI Help Desk at 800 868 2505 You can submit professional and institutional claims including corrected and secondary claims through My Insurance Manager at no charge View the tutorials on filing claims on our website If you would like a live demonstration or training on e claims contact your provider advocate to schedule an appointment You can also email Provider Education bcbssc com to request this education BlueCross BlueShield of South Carolina is an independent Page 81 licensee of the Blue Cross and Blue Shield Association EDI FAQ South Carolina Question Ho
3. For your convenience you can download the Health Professional Application to file claims and update from our Forms page on our website File Application Updates e f your information is not currently in our provider management data system or if you are joining a new group or practice please complete and return the entire application e f you have changed your Tax ID number complete only the Request to Change Tax ID form You will need to submit a copy of your TIN confirmation before we will update your profile The IRS will send this confirmation to you If you have any questions about your Tax ID number you can visit the IRS website at www irs gov e For all physical address changes complete the Change of Address form from the Credentialing Provider Updates page To access these forms go to www SouthCarolinaBlues com and click on Providers Then click Forms Choose the appropriate form from the list Email completed forms to provider cert bcbssc com or you can mail or fax to BlueCross BlueShield of South Carolina Provider Certification AX B20 l 20 at Alpine Road Columbia SC 29219 0001 Fax 803 264 4795 These forms are not applications to join any of the health care networks They allow you to file claims and enable BlueCross to process the claims as appropriate This is not a guarantee of payment BlueCross BlueShield of South Carolina is an independent Page 7 licensee of the Blue Cross and Blue Shield Association South
4. QX QY and QZ for supervision of monitored anesthesia care MAC We will not reimburse CRNAs for MAC e QS Monitored anesthesia care service must appear in the second modifier field e G8 Monitored anesthesia care for a deep complex complicated or markedly invasive surgical procedure must appear in the second modifier field e G9 Monitored anesthesia care for a patient who has a history of severe cardiopulmonary condition must appear in the second modifier field BlueCross BlueShield of South Carolina is an independent Page 65 licensee of the Blue Cross and Blue Shield Association South Carolina Anesthesia Risk Factors There are three modifiers anesthesiologists or nurse anesthetists can file indicating they have added time limits when the physical status of the patient presented a serious health risk They must place these modifiers in the second modifier field of the claim form BlueCross will only pay risk factors if the physician modifier AA on the primary anesthesia code administers the anesthesia personally There will be no separate reimbursement for risk factors for CRNAs or anesthesiologist supervision of CRNAs even if they report it separately Risk Modifiers P 3 Add one time unit when a patient has a severe systemic disease such as uncontrolled diabetes or hypertension requiring medication P 4 Add two time units when a patient has a severe systemic disease that is a constant threat to life such as seve
5. patient s eligibility and benefit coverage You can also call the number on the back of the member s ID card BlueCross BlueShield of South Carolina is an independent Page 36 licensee of the Blue Cross and Blue Shield Association South Carolina Precertification Each Blue Plan establishes its own precertification requirements It is important to complete this process before treating a member After verifying eligibility and benefits ask to be transferred to the precertification or utilization review area or ask for the direct precertification number Generally the precertification number is on the membere ID card Blue Cross and Blue Shield Plans launched a new tool on January 1 2014 that will let you access out of area members Blue Plan Home Plan provider portals to conduct electronic pre service review The term pre service review refers to pre notification pre certification pre authorization and prior approval among other pre claim processes You will be able to access our version of this tool through My Insurance Manager Electronic Provider Access EPA will let you use My Insurance Manager to gain access to a BlueCard member s Home Plan provider portal through a secure routing mechanism Once in the portal you will have the same access to electronic pre service review capabilities as you would with My Insurance Manager You will not need a separate login once you get to the Home Plan landing page The availabi
6. remember to ask to see their current member identification cards ID cards at each visit This will help you identify the product the member has and get health plan contact information It will also help you with claims processing Please note that all ID cards do not look the same and are for identification purposes only They do not guarantee eligibility or payment of your claim Please refer to our 2014 Member Identification Card Reference Guide on www sSouthCarolinaBlues com if you have questions about BlueCross identification cards Sample PPO ID Card South Carolina Member Name Member s Name Jane Q Doe Member ID Membere ID Number ABC123456789012 il eee ee eee Office Visit Managed Pharmacy DEN 004336 Office Visit lt Copayment RxGRP SCB15 Bid oe Dore Amount Program Specialist Visit Plan Code 380 may or may cb Mammography Network Routine Visit Wgd Mammography M graphy not be listed Network Coverage on the card www SouthCarolinaBlues com Important Facts About the ID Card Prefix e Using the correct ID card prefix is critical for electronic routing of specific HIPAA transactions to the appropriate BlueCross and or BlueShield Plan e Itis important to capture all ID card data at the time of service e Do not assume that a member s ID card number is his or her Social Security Number e Be sure all of your system upgrades accommodate the ID card alpha prefix and all characters that follow it e Do not add de
7. By placing our publications on the website we can provide you with important information quickly and accurately Provider Advocates Our Provider Relations and Education staff focuses on providing training and support to health care professionals They serve as liaisons between BlueCross and the health care community to promote positive relationships through continued education and problem resolution The staff is available for on site office training and participation in regional practice manager meetings They can help you with Education and training on all BlueCross programs Requirements for compliance with rules and regulations of the plan The BlueCard program Medicare Advantage Electronic claim filing updates and changes HIPAA issues Problem identification and resolution General service information and implementation of changes Our provider advocates cover the state of South Carolina and contiguous counties in Georgia and North Carolina You can contact the Provider Education department by emailing Provider Education bcbssc com or by calling 803 264 4730 We will route your inquiry to the appropriate staff member for resolution BlueCross BlueShield of South Carolina is an independent Page 6 licensee of the Blue Cross and Blue Shield Association South Carolina Section 2 Provider Information Management File Application To file claims to BlueCross BlueShield of South Carolina you must complete a provider file application
8. Carolina Credentialing Credentialing for Network Participation BlueCross supports several provider networks including e Preferred Blue the Federal Employee Program FEP also uses this network e State Health Plan e Medicare Blue and Medicare Blue Saver BlueCross gives potential network applicants the South Carolina Uniform Credentialing Application SCUCA specific network contracts and professional agreements for network participation The South Carolina Uniform Credentialing Application is available in the Providers area of the website Click on Forms Credentialing Provider Updates and Credentialing For contract or professional agreements email cred fax bcbssc com with your name mailing address and the specific network contracts you need To apply for network participation you must complete the application attach the required documentation and submit the entire package to BlueCross We will notify you of any missing or incomplete information The average processing time for credentialing is 90 business days from when we receive a completed package Any missing or incomplete information will delay the credentialing process You must submit this required documentation with your application State license s Current DEA certificate Proof of malpractice coverage including supplemental coverage Board specialists certificate if applicable Electronic Claims Filing Requirement form page 10 of the SCUCA application Autho
9. Refunds There may be times when we must request refunds of payments we previously made to you When refunds are necessary we notify you of the claim in question 30 days before any adjustment The notification letter explains that we will deduct the amount owed from future payments unless you contact us within 21 days If you identify we made an overpayment and have not received a notice from us you can return the overpayment with the Overpayment Refund Form found on our website Provide documentation supporting the refund and include a check for the appropriate amount BlueCross BlueShield of South Carolina is an independent Page 56 licensee of the Blue Cross and Blue Shield Association South Carolina Section 12 Remittance Advice Remittance Types Institutional and professional health care providers receive 835 remittance advices and Electronic Funds Transfers EFTs The Electronic Remittance Advice ERA or 835 is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1 format Practices facilities and billing companies use these files to automatically post claim payments into their systems The State Health Plan issues remittances and EFTs twice a week All other plans issue payments once per week Patients are responsible for any amounts shown in the Patient Liability Deductible column and the Other column You can view or print remittance advices by logging into
10. agreement to the member even for used equipment that the member purchases following rental The participating DME supplier must always inform the member about any DME warranty the manufacturer provides The DME supplier agrees to provide all DME services supplies and orthotic and prosthetic devices if applicable according to these standards Free delivery Free installation 24 hour emergency services seven days a week by both technicians and professionals Rental equipment repair and maintenance service same day service if necessary Clinical professionals for patient education and home management Where necessary graphically illustrated patient education and instruction manuals Availability of standard economical models that meet a patient s needs and quality standards DME Rental vs Purchase BlueCross has the option of approving either the rental or purchase of DME Based on medical necessity we may approve rental for a specified number of months or up to the purchase allowance We may also approve a member to purchase DME We will reimburse DME purchases when the patient receives the equipment not at the time of order We consider rented DME purchased once the monthly rental allowance equals the purchase allowance The patient then owns the DME and the DME supplier cannot bill the member or BlueCross for additional rental or purchase of the equipment After the rent up to purchase has been met you can bill for supplies and medicall
11. are not limited to Hospital beds oxygen tanks crutches etc Patient s Address Field 5 on CMS 1500 Health Insurance Claim Form or Loop 2010CA on the 837 Professional Electronic Submission Ordering Provider Field 17 on CMS 1500 Health Insurance Claim Form or Loop 2420E line level on the 837 Professional Electronic Submission Place of Service Field 24B on CMS 1500 Health Insurance Claim Form or Loop 2300 CLM05 1 on the 837 Professional Electronic Submissions Service Facility Location Information Field 32 on CMS 1500 Health Insurance Form or Loop 2310C claim level on the 837 Professional Electronic Submission File the claim to the Plan in which state the equipment was shipped to or purchased in a retail store Wheelchair is purchased at a retail store in South Carolina File to BlueCross BlueShield of South Carolina HIPAA Place of Service 99 Wheelchair is purchased on the Internet from an online retail supplier in Ohio and shipped to South Carolina File to BlueCross BlueShield of South Carolina HIPAA Place of Service 12 Specialty Pharmacy Types of Service Non routine biological therapeutics ordered by a healthcare professional as a covered medical benefit as defined by the members Plan s Specialty Pharmacy formulary Include but are not limited to injectable infusion therapies etc Referring Provider Field 17B on CMS 1500 Heal
12. choose to rely on your vendor to provide you with the necessary upgrade to capture the applicable data it may be prudent to validate that the vendor has supplied all the necessary data for two reasons e ltis the provider s responsibility to be compliant If you are not compliant you risk having us return claims or even fine you for non compliance Vendors are not covered entities under HIPAA Most vendors will do the best they can to assist their clients in becoming HIPAA compliant but it is critical for you to ensure that your software upgrade meets the HIPAA requirements e The capture of additional data usually means changes in business processes You may need to change procedures or alter workflow By understanding the new data you need to capture you can plan where to make any necessary changes in your office Understanding the data requirements however is not easy You may want to consider getting expert assistance especially if you are a multi specialty practice If you decide to begin the task of validating your data requirements yourself you should get a copy of the SIGs BlueCross BlueShield of South Carolina is an independent Page 87 licensee of the Blue Cross and Blue Shield Association South Carolina EDIG Trading Partner Enrollment Form Instructions Enrollment with the EDI Gateway requires prospective trading partners to complete and submit e The BlueCross EDIG Trading Partner Enrollment Form an example is on the
13. cross over automatically from the Medicare payer You can verify claim status through My Insurance Manager Medicare Provider Number When BlueCross has a Medicare location number Tax ID number or Unique Physician Identification Number UPIN that is different from the information that Medicare has it delays claims processing If your Medicare provider number changes or if you have not previously given BlueCross your Medicare provider number please submit your current Medicare provider number to your contracting specialist BlueCross BlueShield of South Carolina is an independent Page 52 licensee of the Blue Cross and Blue Shield Association South Carolina Medicare Non Automated Cross Over System You can submit these claims electronically through the X12N HIPAA compliant format or by using My Insurance Manager Medicare Automated Cross Over System Automated Cross Over Policy Benefit e State Health Plan e FEP Automated Cross Over Policy Option e BlueCross Medicare Supplements e Indicated by automated claim filing on the members ID card Sample ID Card Y South Carolina MEDIGAP Member Name SUBSCRIBER NAME South Caroli Member ID South Carolina Customer Service 1 800 868 2500 XXX1234567890 Caims Pharmacy ext 43475 Other questions ext Providers 1 800 868 2510 RxBIN Or 1 803 788 8562 RxGRP Members Providers BlueCross BlueShield of South Carolina PLAN CODE PO Box 100300 PLAN Columbia SC 29202 3300 An
14. guarantee of eligibility or benefits When a member provides your office with his or her FEP BlueDental ID Card it is important to also ask for his or her medical ID card The medical ID card is important because by law the member s medical plan is the primary carrier Sample FEP BlueDental ID Card GH siuesnieia FEP BlueDental Se Ee Service within the U S call LAST NAME Present this card at each visit along Cold be tie EE FIRST_NAME _ with your medical card if applicable 651 994 2583 for coordination of benefits This card is ID Number XXXXXXXXXXXX DEPENDENTS for identification only and nota guarantee of benefits or eligibility For claims submission purposes use the if the member has dentai member s identification number coverage only forward claims io Program FEP BLUEDENTAL Group Number 880000 8000 Claims should be submitted to Dental Claims medical carriers for primary PO Box 75 coverage and not directly to Minneapolis MN 55440 0075 denial if member has medical coverage www fepblue org FEP BlueDental Printed 10 9 2013 216 WFEP Seq 1 Benefits and Eligibility FEP BlueDental recommends that you verify coverage for the date of service Call the FEP BlueDental Customer Service department at 855 504 2583 How to File FEP BlueDental Claims The mailing address for FEP BlueDental claim forms is FEP BlueDental Claims P O Box 75 Minneapolis MN 55440 0075 BlueCross BlueShield of South Carolina is an i
15. member information call e South Carolina 800 868 2510 e Columbia Lexington Area 788 8562 e Out of State 800 334 2583 For BlueCard member information members who have coverage with another BlueCross plan outside of South Carolina 800 676 BLUE 2583 For State Health Plan member information call 800 444 4311 For FEP member information call 888 930 2345 See our VRU Guide in the Education Center of our website for information you ll need and tips on navigating menu options If you still have questions about eligibility benefits or claims My Insurance Manager has the answers If you have not visited the website recently please go to www sSouthCarolinaBlues com and sign into My Insurance Manager for the most efficient and user friendly experience Fax Back Our Fax Back option is also available through the VRU Simply enter your fax number and we will fax the member s benefits or claim status directly to you You will usually receive the fax in less than five minutes and you can keep it in the patient s file for future reference For BlueCard members the VRU is only available for claim status inquiries To check eligibility and benefits please call 800 676 BLUE 2583 or use STATchat in My Insurance Manager BlueCross BlueShield of South Carolina is an independent Page 96 licensee of the Blue Cross and Blue Shield Association South Carolina STATchat Call a Provider Services Rep Online STATchat is a
16. no unauthorized person can access protected health information PHI BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association Page 92 South Carolina My Insurance Manager My Insurance Manager is an online tool providers can use to access these options Benefits and Eligibility Claims Entry Prior Authorization Request and Status Claims Status Remittance Information Your Mailbox EDI Reports My Insurance Manager is safe secure simple and most of all it s free For weekly maintenance My Insurance Manager is not available on Sunday evenings from 5 p m until midnight Home M INSUR ANCE MANAGER Create a Profile bg wm Username p Welcome to My P P SS Insurance Manager 7 Log in to file a claim check benefits or Get Login Help and more If you have never gt registered you will need to create a profile Create a Profile Browser Requirements Latest Features For predictable reliable performance we recommend viewing My Insurance Manager using one of these browsers Firefox Safari S Internet Explorer amp If you need assistance using My Insurance Manager please call our Provider Relations and Education team at 803 264 4730 Outside of Columbia call 800 288 2227 extension 44730 STATchat Upgrade Check Your Firewall You may need to change your firewall settings so you can continue enjoyin
17. on the vendor involved Question Do I need to go through a vendor or can use the Web applications Answer Either is acceptable The volume of claims that your office files will determine which is most practical and cost effective for you Question What is the cost for filing claims on the BlueCross website Answer _ There is no cost other than for the computer and Internet connection The website is totally free Question How do get a list of certified vendors Answer We publish a list of certified vendors in the HIPAA Critical Center at www HIPAACriticalCenter com BlueCross BlueShield of South Carolina is an independent Page 82 licensee of the Blue Cross and Blue Shield Association South Carolina Question Who is the best vendor or whom do you recommend Answer We do not make specific recommendations but offer the list of certified vendors who currently transmit to us electronically Question What types of claims can be sent electronically Answer All claims We accept institutional facility and professional medical and dental claims including corrected and secondary claims This also includes e claims in My Insurance Manager Question Can I send attachments electronically Answer Currently there are no claim attachments that we require you to submit electronically BlueCross BlueShield of South Carolina is an independent Page 83 licensee of the Blue Cross and Blue Shield Association South Carolina Se
18. outlined above e Local anesthesia Anesthesia Frequently Asked Questions FAQ Question Will BlueCross cover anesthesia when a physician provides it with a non covered service Answer No When a physician provides anesthesia services with a non covered service BlueCross does not cover the physician s charge for the anesthesia with the exception of general anesthesia for dental surgical procedures that are covered under a separate dental contract Question When does anesthesia time begin and end Answer Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area It ends when the patient may be safely placed under postoperative supervision Question Does BlueCross cover anesthesia when an attending or assisting physician administers it Answer BlueCross does not provide benefits when an attending or assisting physician administers anesthesia with the exception of regional anesthesia administered during delivery BlueCross BlueShield of South Carolina is an independent Page 68 licensee of the Blue Cross and Blue Shield Association South Carolina Maternity Care Most BlueCross plans offer maternity benefits that require a member to notify the plan within the first trimester of a pregnancy A member who does not notify the plan may receive a penalty Maternity benefits for covered members are subject to reimbursement under these con
19. us for precertification BlueCross BlueShield of South Carolina is an independent Page 78 licensee of the Blue Cross and Blue Shield Association South Carolina Certificate of Medical Necessity CMN Form For FEP only DME suppliers must file all initial claims for the rental or purchase of DME with a completed CMN You can submit the CMN Form found on Medicare s website at www CMS gov When prescribing DME the patient s physician should complete the CMN form BlueCross may in some cases request additional medical records and documentation from the prescribing physician This additional documentation includes but is not limited to e Aclinical assessment in narrative form including past and present history and signs and symptoms expected to improve with the use of the equipment e Reports of any clinical diagnostic tests e g pulmonary function complete blood count CBC oxygen and saturation etc that show evidence of the diagnosis and need for the equipment e Written verification that the physician has tried other methods of treatment such as drug therapy gravity feeding and supplemental oxygen etc and has proven them unsuccessful or noted these methods were not Clinically indicated e A report of polysomnography studies documenting a diagnosis of obstructive sleep apnea The report should indicate at least one four hour sleep session as well as a session using the monitor that shows a significant improvement A memb
20. 02 3185 Outside Columbia SHP Prescription Drugs The SHP has a three tier prescription drug program with either a drug card and or mail service benefits Catamaran is an independent prescription drug company that contracts directly with the SHP For more information about prescription drugs including a list of in network providers visit www MyCatamaranRX com or call 855 901 7322 SHP Fee Allowances You can access the SHP s fee schedule at www SouthCarolinaBlues com by logging into My Insurance Manager SHP Precertification You can request precertification at www SouthCarolinaBlues com by logging into My Insurance Manager or by calling Medi Call at 800 925 9724 Medi Call is a division of BlueCross BlueShield of South Carolina that handles the medical precertification and case management services for the SHP SHP Inpatient All SHP inpatient procedures and admissions require precertification The SHP has a special deductible for each emergency room visit The plan waives this special copayment if the hospital admits the patient BlueCross BlueShield of South Carolina is an independent Page 20 licensee of the Blue Cross and Blue Shield Association South Carolina SHP Outpatient There is a special copayment for each outpatient visit These outpatient procedures require precertification for SHP members MRI MRA Septoplasty Sclerotherapy in an outpatient or office setting CT scan Chemotherapy radiation therapy one time noti
21. Card Eligibility and Benefits 2 00 cece eee reer eee eee eter etree eee eee eet aae nese eee eee tecaaaeeeeeeeeneneeaaaes 36 BlueCard PreGertiliGQtiGn TE 37 BlueCard Claim Submission ccccccccccccccccce cece cece cece cece cece cece ee ee EEE EEE EEE EEE EAEE AREE EEN A KANA KAN RANSA 37 BlueCard Merl TEE 38 Ancillary GUGM S sieves cs caine annan anainn enaena Ene e en Ea oi ena ena eira iaiaaeaia aaa diaa ia Eaa E ANAAO EEA E 38 BlueCross BlueShield of South Carolina is an independent Page 3 licensee of the Blue Cross and Blue Shield Association South Carolina Traditional Medicare Related Claims cece ccceeee ee eee eterna eee e eee aaaeeeeee tees ee tneecaaeeeeeeetenee 41 BlueCard Contacts and Hesources ee eee eee a eee eee eae eee aaa 41 Section 9 BlueCross Dental Plans isis sctccecetetccecesacanecetaceeeansasancradaceteaueuaatecetacetesueuaateneaadedenssiedssecssscecassceexeecsseesed 42 Commercial Dental l n uteteges eeetetabreueges eeu tere ege EEEE EEEE EEE AEAN E A AENIL 42 Dental TIR 43 SE 45 State Dental and Dental Plus Plans 0000 00 02 eeee cess eee teeta eee eee eae eee eee aaa aaa eee 47 Section eege ctadaca ian ineutcesasauavenessuaeeuaea 49 GOB E S A niente a enc E 49 Other Factors Under GOB Regulations irese rnense a a aaa ana aa aE been nee ENEE EENEG 51 Medicare Secondary and Supplemental Policies cccceeeceeeeeeeeeccneee esse eee eeeaaaeeeeeeeeeeeeeaaeeeeeeeeeeeeegeeenaaaes 52 Medicare Pr
22. GMISSION creciera eee einen Gaerne EEEE NESA 61 Newborn Hospitalizations TEE 61 Notification of Admission Status Change 62 Case Management i 0 csieecieert eee cdeneeetei neta ieieninaee tenet ie 62 ege e Ee 62 C n rrent Cale eccrine Edert eege deeg ef eege eeano nasaha tan naika deaths 63 Medical to Surgical Concurrent Care by Different Phwasclans 63 Section 14 Medical Guidelines 1cccceeeeeeeeeee eee ee eee e ee eee ane e eee sees eae ee eee eee eee eee eee eee 64 Multiple Surgenes 0 csniet iiini EENKEER EEA NKAN dati t nian 64 Assistant SUIQ OM E 64 Bilateral Procedures esir reiini REEE ie acts eis Freee detente 65 Anesthesia RISK Factors teien iiine iir EEEE EENE EEEE EEEE EENE EAE EEEE EE EERE A 66 Other Anesthesia ocres aeeie EEEE EEEE E deer SEEE AEAEE EEE ENEE E ANEA EAEE aT 66 Amesthesia EE 67 Anesthesia Frequently Asked Questions EA 68 EN lee 69 Benefits Outside of Global Garg seekukEERukESeEERKEEERAESSSEENNEEKEEEEAEESSEKEEKEKEEAKEESEEEENEEEA EERSTEN 70 Accessing Medical Policies ikrr innara anena anena nEaN vii KK NA dee ede eed AEEA EEANN Aaaa a 71 Section 15 Medical ROViIGW siccscccsccccccsccscstscscocenscenssssexscoresosussrerersconecenncssessteeeeedeeadsuscesesanseassesseecssonnnsstearsccadssnans 72 ENTENTE edd 72 ee E 72 Inappropriate E 73 Levels of Appeal eege ENKEN EEGENEN eid Heenan ie recede 73 Solicited Records REQuests AA 75 BlueCross BlueShield of South Carolina is an independent Pag
23. IBER S LAST NAME Member ID www SouthCarolinaBlues com XXX123614046483 Le CG South Carolina Customer Serve 1 800 822 1185 PLAN DENTAL BlueCross BlueShield of South Carolina PLAN CODE 380 P O Box 6000 Greenville SC 29606 6000 An independent licensee of the Blue Cross anc Blue Shield Association www SouthCarolinaBlues com Sample Commercial Medical and Dental ID Card a CG DH D Gl South Carolina e d H SUBSCRIBER S FIRST NAME SUBSCRIBER S LAST NAME wurw SouthCarolinaBlues com j Customer Service 1 800 760 9290 Member ID South Carolina Dental Customer 1 800 222 7156 XXX123614046483 e PPO Network Providers 1 800 810 2583 Precertification 1 800 334 7287 RxBIN 004336 Providers file claims with the local BlueCross and or Loge 1 008 490 1082 BlueShield Plan where member received services e k 1 888 963 7290 RxGRP SCBXX Preauthorization required for some hospita outpatient PLAN CODE 380 procedures and all hospital inpatient admissions BlueCross BlueShield of South Carolina MRIMRA PET CT requires authorization to ensure PO Box 100300 MAMMOGRAPHY NETWORK benefit payment Columbia SC 29202 An indi t h f the Blue Ci Report all emergency admissions within 24 hours and B ries A me x www SouthCarolinaBlues com PPO MHA CAREMARK Pharmacy benefits administrator BlueCross BlueShield of South Carolina is an independent Page 42 licensee of the Blue Cross and Blue Shield Ass
24. My Insurance Manager You can determine a claim s submission channel by reviewing the BlueCross claim number Electronic claims through the HIPAA X12N or Web formats will result in faster reimbursement reduced administrative costs and the elimination of keying errors e Electronic claim claim submitted through clearinghouse Example 1C00001 11000 e Web claim claim submitted through our website www SouthCarolinaBlues com Example 33000000W0000 e Superbill claim claim submitted for professional providers who want to file multiple charges for one date of service Example 33000000P0000 e Hardcopy claim claim mailed hardcopy Example 1600011110000 BlueCross BlueShield of South Carolina is an independent Page 57 licensee of the Blue Cross and Blue Shield Association South Carolina My Remit Manager My Remit Manager www MyRemitManager com is an online tool you can use to search remits by patient account number and check number We offer My Remit Manager free to all providers who receive Electronic Funds Transfer EFT payments and electronic remittance advices My Remit Manager Accepts 835s from all commercial BlueCross lines of business Works independently of your practice management system or clearinghouse With My Remit Manager you can View ERA information by file and see all details You have the option of viewing the specific American National Standard Institute ANSI details the payer sends or
25. No 023457 Plan PPO 987654 Office Visit 15 Bdnefit Plan HIOPT Specialist Copay 15 Effective Date 00 00 00 Emergency 75 50 Sr The PPO in a suitcase logo may appear in the lower right corner of the ID card Plan Code 123 Deductible The three character alpha prefix Ge Kal South Carolina Member Name 00 Specialist Visit Routine Visit SouthCarolinaBives com The blank empty suitcase logo may appear in the lower right corner of the ID card The three character alpha prefix BlueCard ID cards have a suitcase logo either as an empty suitcase or as a PPO in a Suitcase The PPO in a suitcase logo indicates that the member is enrolled in a PPO product You will be reimbursed according to the BlueCross PPO provider contract The blank empty suitcase logo indicates that the member has out of area coverage that is not a PPO product Benefit products that display a blank empty suitcase logo on ID cards include Traditional HMO Health Maintenance Organization POS Limited benefits products BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association Page 35 South Carolina Alpha Prefix BlueCross uses a three character alpha prefix at the beginning of members ID numbers to identify and correctly route out of area claims The alpha prefix identifies the BlueCross and or BlueShield Plan to which the member belongs It is
26. S P O BOX 600601 COLUMBIA SC 29260 FAX 803 264 8104 GROUP amp INDIVIDUAL AX F25 ATTN MEDICAL APPEALS 1 20 at ALPINE ROAD COLUMBIA SC 29219 FAX 803 264 4172 PPO PROVIDER SERVICES AX 620 ATTN MEDICAL APPEALS 1 20 at ALPINE ROAD COLUMBIA SC 29219 FAX 803 264 4172 FEDERAL EMPLOYEE PROGRAM FEP R ALPHA PREFIX GROUP amp INDIVIDUAL ZCY ALPHA PREFIX PREFERRED BLUE AND ALL OTHER BlueCross BlueCard Note This form is intended for use by physicians and other health care professionals in South Carolina If you are located outside South Carolina and have claims questions reviews or appeals please direct them to your local Blue Plan BlueCross BlueShield of South Carolina is an independent Page 74 licensee of the Blue Cross and Blue Shield Association South Carolina Solicited Records Requests There are times when BlueCross may request medical records from you for a patient We may request records in order to determine medical necessity or apply benefits to a claim or we may request records for risk adjustment or Healthcare Effectiveness Data and Information Set HEDIS review When you receive a request for records please respond to the appropriate mailing address or fax number provided with the request If we need records from your office for a member with BlueCross insurance through another BlueCross and or BlueShield plan you will receive a letter from Verisk ordering the records Having a sin
27. SCPARTD 2 23553 RxPCN PPOSC BlueCross BiveShield of South Caroling Issuer 80840 Prowders Do not bil Mecicare Medicare loug PO Box 100191 e Charges apply to 207 arl cipating providers Part D Plan Benefit Medica reR Browder fle clams with the local BiveC 1053 andor Catumbia 5C 29102 3091 Prescription Drug Coverage An independent licensee of the Bue Cross CMS H4209 XXX SlucSh eid Plan where member recoved serv ces Srg Sloe Shieh Aen A30 Medicare Blue Saver Medicare Blue Saver is a Medicare Advantage PPO plan that provides benefits for traditional Medicare covered services without Medicare Part D prescription drug coverage Sample Medicare Blue Saver ID Card South Carolina MEDICARE BLUE le A SAVER Member Name www scbivesmedadvantage com SUBSCRIBER NAME Les H South Carolina Members Provicers 1 888 645 6025 Member ID TTY Users 1 888 645 6023 ZCT012345678901 Vision Dental Services 1 877 225 7460 i EH ry OH Members Use network services for maximum Prior Authorization 1 800 327 3183 benefits ext 25553 BlueCross BlueShield of South Carolina Providers Do not bell Medicare Medicare IMUNG PO Box 100191 charges apply to non participating providers Columbia SC 29202 3191 Providers file claims with the local BlueCross and or An independent hoensee of the Blue Cross Bir eld Plan where member revewed services and Blue Sheid Assocation A33 BlueCross BlueShield of South Carolina is an independent Pag
28. SouthCarolinaBlues com BlueCard Authorization Select My Insurance Manager www southCarolinaBlues com BlueCard Claim Status Select My Insurance Manager BlueCard Program Provider Manual www sSouthCarolinaBlues com Email Provider Education bcbssc com Provider Education 800 288 2227 ext 44730 BlueCross BlueShield of South Carolina is an independent Page 41 licensee of the Blue Cross and Blue Shield Association South Carolina Section 9 BlueCross Dental Plans Commercial Dental Plans There are commercial dental plans that use a network of participating providers and other plans that do not have a network Members may visit any provider however an out of network provider may balance bill for the difference in BlueCross allowable and actual charges Levels of dental coverage for these plans include e Preventive care e Restorative care e Major restorative care e Orthodontic care optional How to Identify Commercial Dental Plan Members The ID card shows the plan members identification number and plan code number On the reverse side is the customer service telephone number Depending on the plan coverage may be for dental only or offered in conjunction with a membere health benefits Here are examples of member identification cards from our commercial group plans that offer dental benefits Sample Commercial Dental Only ID Card South Carolina SUBSCRIBER S FIRST NAME SUBSCR
29. State Claims P O Box 100605 Columbia SC 29260 For prompt payment we encourage electronic claims submission You should transmit claims in the HIPAA 837 format under the appropriate payer codes Claim Status You can submit claim status inquiries by visiting www SouthCarolinaBlues com and logging into My Insurance Manager You can also access claim status through the VRU by calling 800 444 4311 Claim Payment If you do not receive payment for a claim it is not necessary to resubmit the claim This confuses members because they receive multiple EOBs You should check claim status by either calling our VRU at 800 444 4311 or using My Insurance Manager at www SouthCarolinaBlues com In some cases a claim may pend because medical review or additional information is necessary When resolution of a pended claim requires additional information from you we will notify you in writing via your remittance or a letter requesting the additional information Corrected Claims If an adjustment for charges is required resubmit a corrected claim with the correct charges Please do your best to bill correctly the first time and limit the number of corrected claims that you file to us Corrected claims require manual intervention and may decrease your claim adjudication times Appeals If you are dissatisfied with an initial claim determination you can appeal a claim disposition by using the Medical Review Form on www SouthCarolinaBlues com Be sure
30. aims for imaging services based upon the terms of your BlueCross agreement Non emergent procedures requiring prior authorization are Computerized Axial Tomography CAT scan Positron Emission Tomography PET scan Magnetic Resonance Imaging MRI Magnetic Resonance Angiography MRA You can view the NIA Reference Guide Claim Resolution Matrix a list of group prefixes that require precertification for these services and other radiology information in the Radiology Precertification section of the Education Center at www SouthCarolinaBlues com Please note some of the groups include ASO plans as well Each Blue Plan establishes its own prior authorization requirements It is important to complete this process before treating the member Be sure to verify precertification requirements when verifying eligibility and benefits Generally the prior authorization number is on the members ID card Note e The ordering physician should get the prior authorization The provider rendering the service should verify that he or she has received the precertification Failure to do so may result in non payment of the claim e We do not require precertification for emergency room observation and inpatient imaging procedures e We exclude members with Medicare primary coverage from this NIA agreement Visit www RadMD com or call 866 500 7664 to request a precertification or check the status of a request You can also access the NIA website by visiti
31. al Contact Informa ation BEE 91 Section 19 www SouthCarolinaBlues cCOm 1ccccceeeeeeeeeee ee eeeee ee ee esas ee eeaa eee eeea eee eeea eee seeadeesaeeaeeeeee eee aeeeeeeeeeeneee 92 My Insurance Manager ceneni NECE EEEE EEEE TEAN AAEE AAA AEEA AAEE EEEE EREE EEE 93 My Insurance Manager EA 95 Section 20 PPO Voice Response Unit and STATchat sssussnssnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn nnmnnn nnn 96 Me each Peeecice A cd extecead acicecteduecaace dase iced denaceradetcences vite eee eee eee 96 ST 96 Section 21 Communicating With BME CrOSS iaccecccads cece conecectuataeeacscededcenadeaneecceedscauassseeacecsdsdauavessasceccasetaaetecedduaans 98 BlueCross BlueShield of South Carolina is an independent Page 5 licensee of the Blue Cross and Blue Shield Association South Carolina Section 1 General Information Provider Services Our website www SouthCarolinaBlues com offers quick access to member eligibility and benefits claim entry claim status remittance advice and other important information by logging into My Insurance Managers You can save time by submitting your questions through Ask Provider Services Provider News and Updates We have many informational publications for providers including this manual These publications are available on our website Here s how you can find these publications e Go to www SouthCarolinaBlues com e Click Providers e Click Education Center
32. als and other health care providers If a provider is not in the BlueEssentials EPO network we will not cover services unless in the event of an emergency While the range of benefits is the same among plans the value of benefits will vary Always verify coverage for members as eligibility may change based on premium status BlueCross BlueShield of South Carolina is an independent Page 29 licensee of the Blue Cross and Blue Shield Association South Carolina Transition of Care If a BlueEssentials member is under the care of a physician who is not in the BlueEssentials network they can request special consideration to have benefits applied at in network levels Members can submit a Transition of Care form for consideration Upon review by our Utilization Management area we may approve a member to continue care with the out of network provider for a specified time You can find the Transition of Care form on our website How to Identify BlueEssentials Plan Members Only NEW individual product lines access the new BlueEssentials network Alpha prefixes are ZCU ZCF and ZCQ These ID cards also distinguish the new networks by having BlueEssentials Network and Exclusive Provider Organization on the cards Benefits are only available in network See the back of the ID card The suitcase in the lower right indicates the network that members access when out of state Individual policies only provide coverage to the subscriber A pa
33. an s own service area File ancillary claims incurred in a contiguous county directly to the members Plan but solely for its members who live or work in its service area File claims for all other members to the local Plan as defined for ancillary services Claims filing rules for contiguous area providers are based on the permitted terms of the provider contact which may include Provider location e in which Plan service area the provider s office is located Provider contract status with the two contiguous counties i e is the provider contracted with only one or both service areas The member s Home Plan and where the member works and resides i e is the member s Home Plan with one of the contiguous counties Plans The location of where the services were received i e does the member work and reside in one contiguous county and see a provider in another contiguous county BlueCross BlueShield of South Carolina is an independent Page 40 licensee of the Blue Cross and Blue Shield Association South Carolina Traditional Medicare Related Claims When Medicare is the primary payer submit claims to your local Medicare carrier Most Blue claims are set up to automatically cross over to the members Blue Plan after being adjudicated by the Medicare Carrier These guidelines will help you handle claims for Medicare beneficiaries who also have BlueCross coverage e Enter the correct Blue Plan name as the secondary ca
34. an provides the services during the same period of time or the same hospital admission It also may refer to medical and surgical care one physician provides during the same admission Medical to Medical Concurrent Care When two physicians provide care for unrelated conditions at the same time BlueCross pays benefits to each physician if e The physicians are not of the same or similar specialty e g endocrinologist and cardiologist e Each physician is treating the patient for a condition unique to his or her specialty e The admitting physician releases care of the patient to a consulting physician and provides supporting documentation Medical to Surgical Concurrent Care by Different Physicians BlueCross pays benefits for inpatient medical services physicians other than the admitting surgeon perform in addition to benefits for inpatient surgical services under these circumstances e The medical care was not related to the condition causing the surgery and is not part of routine preoperative or postoperative care e The medical care required skills that the admitting or assisting physicians do not possess e Aphysician other than a surgeon admits the patient for medical treatment and surgery becomes necessary Medical Care Benefits more than one visit per day BlueCross reimburses only one level of care when a physician files for more than one service he or she provided to a patient on the same date of service We will provide benef
35. ances and 10 percent for all other covered procedures If a physician performs an operation or procedure in two or more steps or stages BlueCross will limit coverage for the entire operation or procedure to the allowable charge set forth for that operation or procedure Assistant Surgeon There are medical policies that will reimburse for services a physician assistant performs Our current contracts however do not cover services a physician assistant performs and only reimburse for those a licensed MD performs We do have certain instances in which we will reimburse for a physician assistant Use of an assistant surgeon must meet medical necessity for BlueCross to consider reimbursement This results in one physician acting as the primary surgeon and the other acting as an assistant BlueCross provides benefits for an assistant surgeon under these conditions e The assistant is a licensed practicing physician e There is sufficient complexity to the procedure or the patient s condition warrants an assistant e An intern resident or house physician is not available to assist BlueCross BlueShield of South Carolina is an independent Page 64 licensee of the Blue Cross and Blue Shield Association South Carolina Bilateral Procedures File all bilateral procedures to BlueCross on one line with the CPT code and modifier 50 Document one unit DUT The modifier indicates the physician performed the procedure on two sides and BlueC
36. and Blue Shield Association South Carolina Trading Partner Agreements and Supplemental Implementation Guides Trading Partner Agreement In general a trading partner is any organization that enters into a business arrangement with another organization and agrees to exchange information electronically Typically the two organizations develop a contract or agreement to describe this arrangement BlueCross requires providers or their vendors to complete a Trading Partner Agreement TPA You can find the TPA application at www HIPAACriticalGenter com under Enrollments and Agreements Companion Guide A companion guide clarifies the specifics about the data content a provider transmits electronically to a specified health plan For example it may clarify what identification number is needed for the Payer Identifier data element We call our companion guides Supplemental Implementation Guides SIGs since they supplement the HIPAA Implementation Guides These guides address the situational fields that HIPAA allows for and explain how we use these fields You can find all our guides at www HIPAACriticalCenter com Supplemental Implementation Guide SIG There are data elements that we require in all cases these are called required and there are data elements we require only when the situation calls for them these are called situational Many situational data elements are related to the specialty of the physician While you may
37. at amount If the remaining dollar amount is zero or a negative amount then we will not pay any benefits Medicare Carve Out for Assigned Claims Carve out COB requires additional calculations when providers accept assignment of Medicare benefits BlueCross uses these steps to calculate secondary benefits on assigned claims 1 Subtract the Medicare payment from the Medicare approved amount Refer to this as calculation A 2 Calculate normal benefits including appropriate deductibles and coinsurance 3 Subtract Medicare s payment from normal benefits Refer to this as calculation B If this results in a negative amount consider calculation B to be equal to zero 4 Compare calculations A and B Payment will be the lesser of the two amounts BlueCross BlueShield of South Carolina is an independent Page 51 licensee of the Blue Cross and Blue Shield Association South Carolina Medicare Secondary and Supplemental Policies These guidelines will help you handle claims for Medicare beneficiaries who also have BlueCross coverage When Medicare is primary and assignment is accepted Do not charge the patient File the claim to Medicare Receive the Medicare Summary Notice MSN Most claims automatically cross over from Medicare to BlueCross Verify this automatic claims feature before filing a claim to BlueCross If the claim does not automatically cross over from Medicare file the claim electronicall
38. ber pays the premiums If the premium is not current at the end of the third month 90 days we will deny claims We will notify you of a member s premium delinquency 1 When verifying eligibility and benefits through My Insurance Manager and the VRU 2 When verifying claim status through My Insurance Manager and the VRU 3 When reviewing your remittance advice BlueCross BlueShield of South Carolina is an independent Page 32 licensee of the Blue Cross and Blue Shield Association South Carolina Section 8 BlueCard Program The BlueCard program enables Blue Plan members to get health care service benefits and savings while traveling or living in another Blue Plan s service area The program links participating health care providers across the country and internationally through a single electronic network for claims processing and reimbursement The BlueCard program lets you submit claims for Blue Plan members directly to your local BlueCross BlueShield of South Carolina Plan BlueCross will be your point of contact for education contracting claims payment adjustments and problem resolution You can get eligibility and benefits information by calling 800 676 BLUE 2583 Use this number for all members with out of state BlueCross and or BlueShield Plans The BlueCard program applies to all inpatient outpatient and professional claims The BlueCard program includes traditional PPO POS and HMO products These products are optional
39. betes Educator Sports Trainer Massage Therapist Education Specialist Technician Dietician Homeopath Christian Science Practitioner Physical Therapy Assistant Lay Midwife Occupational Therapy Assistant School Psychologist Naturopath Recreational Therapist Acupuncturist Psychology Assistant Providers in Contiguous Counties Re credentialing BlueCross requires all health care providers to go through re credentialing every three years We email or fax credentialing packages to health care practices You must return the packages to us within the allotted time or you could lose your network participation The re credentialing package includes e BlueCross Credentialing Update forms for each practitioner in the practice When submitting include these for each practitioner State license s Current DEA certificate if applicable Proof of malpractice coverage including supplemental coverage Board specialist certificate if applicable e One practice information update form Please email Credentialing Update forms and requested documentation to provider cert bcbssc com or fax to 803 264 4795 BlueCross BlueShield of South Carolina is an independent Page 9 licensee of the Blue Cross and Blue Shield Association South Carolina Mental Health Network Participation Companion Benefit Alternatives CBA is a separate company that manages a mental health network on behalf of BlueCross To participate please complete the Companion Benefit Alternat
40. c com 803 264 8416 brenda bethel bcbssc com 800 222 7156 803 264 7629 803 264 5460 belinda stokes bcbssc com 803 264 9079 david strobel bcbssc com State Health Plan Provider Services Ask Provider Services functionality Phone Fax Donna Frishcosy Manager 800 444 4311 803 264 4204 803 264 2520 donna frishcosy bcbssc com State Health Plan Dental Provider Services Phone Phone Fax Bonnie Tucker Manager FEP Provider Services Phone Fax Cynthia Lagatore Director Pamela Johnson Supervisor FEP Dental Provider Services Phone Fax Chris Jones Supervisor 888 214 6230 Toll Free 803 264 3702 Local 803 264 8109 803 264 7284 bonnie tucker bcbssc com 888 930 2345 Toll Free 803 264 8104 803 264 3325 cynthia lagatore bcbssc com 803 264 3052 pamela johnson bcbssc com 800 444 4325 Toll Free 843 763 0631 803 264 8702 christopher jones4 bcbssc com BlueCross BlueShield of South Carolina is an independent Page 99 licensee of the Blue Cross and Blue Shield Association
41. critical for confirming a patient s membership and coverage Changes to alpha prefixes may appear on your remittance advice Please review this information carefully to make sure claims are routed correctly Examples of ID numbers ABC1234567 ABC1234H567 ABC 12345678901 234 Alpha Alpha Alpha Prefix Prefix Prefix Some ID cards may not have an alpha prefix This indicates that the claims are handled outside the BlueCard program Please look on the back of members ID cards for instructions or telephone numbers on how to file these claims As a provider servicing out of area members you may find these tips helpful e Ask the member for the most current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure you have the most up to date information in your patient s file e Verify with the member that the ID number on the card is not his or her Social Security Number If it is call the BlueCard Eligibility line at 800 676 BLUE 2583 to verify the ID number e Make copies of the front and back of the membere ID card and pass this key information on to your billing staff e Remember Member ID numbers must be reported exactly as shown on the ID card and must not be changed or altered Do not add or omit any characters from the member ID numbers or alpha prefix Eligibility and Benefits Once you ve identified the alpha prefix call BlueCard Eligibility at 800 676 BLUE 2583 to verify a
42. ction 18 HIPAA The Health Insurance Portability and Accountability Act HIPAA became law in 1996 HIPAA portability provisions ensure that insurance companies do not deny individuals health insurance coverage under pre existing conditions when the individual moves from one employer group health plan to another HIPAA includes provisions for administrative simplification The purpose of these provisions is to improve the efficiency and effectiveness of health care transactions by standardizing the electronic exchange of administrative and financial data as well as protecting the privacy and security of individual health information that insurance companies maintain or transmit electronically HIPAA administrative simplification imposes stringent privacy and security requirements on health plans health care providers and health care clearinghouses that maintain and or transmit individual health information in electronic form In addition HIPAA mandates that EDI complies with the adoption of national uniform transaction standards and code sets and requires new unique provider identifiers The BlueCross Gateway processes these ASC X12N Version 4010A1 transactions required by HIPAA 270 271 276 277 278 834 835 837 Health Care Eligibility Benefit Inquiry Health Care Eligibility Benefit Response Health Care Claim Status Request Health Care Claim Status Response Health Care Services Review Benefit Enrollment and Maintenance Health Car
43. ditions Global Care Maternity Benefits BlueCross reimburses for global maternity benefits These benefits include e Antepartum care e Delivery e Postpartum care If a patient leaves her physician s care before delivery the physician should file either office visits or the appropriate antepartum CPT codes as we outline here We may require a statement supporting the reason for the non global charges before reimbursing the provider Some reasons a patient may terminate care are e Patient establishes care with a new practice e Patient moved to another geographic location e Patient has a high risk pregnancy and her physician transfers her to another practitioner If the patient has less than or equal to three visits file single office visits for each date of service For four or more visits file the appropriate antepartum delivery or postpartum CPT code File one DUT for all antepartum codes regardless of the number of visits This is applicable for Preferred Blue FEP the State Health Plan and all BlueCard members BlueCross BlueShield of South Carolina is an independent Page 69 licensee of the Blue Cross and Blue Shield Association South Carolina Benefits Outside of Global Care 1 Lab work e An obstetrical lab panel is reimbursable outside of the global care benefits Please see our medical policy for additional information 2 Fetal non stress test e Eligible for reimbursement in addition to global payment when a prov
44. ds case management you can call the number on the back of his or her ID card to ask how to take advantage of this service Case managers work with the patient his or her family and providers to maximize the use of available health care resources They are knowledgeable about the member s health care benefits and community resources available for patients Retrospective Review BlueCross Retrospective Review Unit reviews claims to make sure the services received by the patient were medically appropriate and met the definition of covered services under the members contracts certificates BlueCross may perform a retrospective review to assess the medical need and correct billing levels for services that providers have already performed Registered nurses handle retrospective reviews but the medical director makes the final determination The nurses claim diagnoses treatments or procedures including but not limited to cosmetic experimental or investigational services that the member s contract certificate may limit or exclude The nurses also conduct medical reviews for possible pre existing conditions BlueCross BlueShield of South Carolina is an independent Page 62 licensee of the Blue Cross and Blue Shield Association South Carolina Concurrent Care Concurrent Care consists of the treatment of one or more diseases or areas of the body when those services are more extensive than consultative services and more than one physici
45. e 25 licensee of the Blue Cross and Blue Shield Association South Carolina How to Identify Medicare Advantage Plan Members Medicare Advantage members have three character alpha prefixes at the beginning of the ID numbers on their insurance cards Their ID numbers begin with ZCT Medicare Blue and Medicare Blue Saver Service Areas The service area for Medicare Blue and Medicare Blue Saver includes these South Carolina counties Abbeville Aiken Anderson Calhoun Cherokee Chester Clarendon Edgefield Fairfield Greenville Greenwood McCormick Laurens Lexington Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union York Allendale Bamberg Barnwell Beaufort Berkeley Charleston Chesterfield Colleton Darlington Dillon Dorchester Florence Georgetown Hampton Horry Jasper Kershaw Lancaster Lee Marion Marlboro Williamsburg Members must be residents of one of these counties to purchase and keep these plans Benefits and Eligibility Providers and enrollees can quickly get the most current member eligibility and benefit information by using My Insurance Manager on our website at www SouthCarolinaBlues com You can also call the Medicare Advantage Provider Services VRU at 888 645 6025 option 3 Balance Billing Providers can collect only applicable copayments or coinsurance amounts from Medicare Advantage members and cannot otherwise charge or bill the members for covered services BlueCro
46. e 4 licensee of the Blue Cross and Blue Shield Association South Carolina Section de r ee EE EE Eegeregie 76 Ambulatory Surgery e 76 MEI VC 76 Home Health ServiC S iesnas inaani nananet ee EN EEE aa Aaaa a AAKA EA TULAN AAAA OAA KANA 76 elef e 77 Skill N rsing He e 77 Long Term Acute Care LTAC cece tec c teeter ett eae eee e eee edad ented eae eee 77 IV Infusion TNer Py EE 77 Durable Medical Equipment DMET eee eeeeeeeeaaaeeeeeeeeeteeaaaaeeeeeeeecegccaaaaeaaaeeeeeeesesecesaeeeeeees 77 DME Rental vs Purchase eee eee iriiri kininis n arinena nana eaaa keai aAa i kaa 78 Deluxe and Special Features AA 78 Certificate of Medical Necessity CMN Fom eee eeeeeeccceee esse eeteecaaeeeeeeeeeeeeccaaeeeeeeeeeeeeeneeaaaes 79 Section 17 Electronic Datainterchan ges ccctcececcctcnas ciate tetsictetat cdots tetedenedatenea tots dumaaebeaadctedaienadcdececisacusassgsesncesecaes 80 CNSR COGS ssc eect tnt wie eee ele ee cede eee secre ee daddeda eed ee vee avereaeceee 80 Electronic Remittance Advice ERA 835 and Electronic Funds Transfer EFT 81 EDI GU E 81 SR AO werreperer errr E A E A errr eee ere E 82 Section 18 HIPAA est enugessEaEeEeEREuESESEESuESESEEEKESESEKEKSEEREEENEEEKESENEEEKEEEEREEEEEESEEEERESEEEEEEEREEEENEEEEEEEEEEEE SS EES EES EEEEEESEEEREE e 84 Transactions and Code Sets EE 85 HIPAA RE EE 86 Trading Partner Agreements and Supplemental Implementation Guides 87 EDIG Trading Partner Enrollment Form Insiruchons 88 Addition
47. e Payment Advice Health Care Claim RN BlueCross BlueShield of South Carolina is an independent Page 84 licensee of the Blue Cross and Blue Shield Association South Carolina Transactions and Code Sets The HIPAA Transactions and Code Sets regulation 45 CFR Parts 160 and 162 required the implementation of specific standards for transactions and code sets by October 16 2003 We met this deadline and are fully HIPAA compliant Applicability The regulation pertains to e All health plans including Medicare Medicaid BlueCross plans employer sponsored group health plans and other insurers e All vendors and clearinghouses e g billing services re pricing companies and value added networks that perform conversions between standard and non standard transactions e All providers including physicians hospitals and others who conduct any of the HIPAA transactions electronically Purpose The intent of HIPAA s Administrative Simplification regulation is to achieve a single standard for claims eligibility verification referral authorization claims status remittance advice e g EOBs and other transactions Adoption of standard transactions should streamline billing enhance eligibility inquiries and referral authorizations permit receipt of standard payment formats that can post automatically to your accounts receivable system and automate claims status inquiries Your Responsibility HIPAA requirements impact the maj
48. e from your practice can create profiles under your Tax ID number All locations need at least one profile administrator The profile administrator will be responsible for approving other staff members pending My Insurance Manager profiles The profile administrator will use his or her Profile Management tab to view approve and or deny a staff member access to My Insurance Manager Submit the information You are now ready to access My Insurance Manager Simply choose the task you want from the menu When you are finished using My Insurance Manager select Exit It is a fast and easy way to find information on your patients with BlueCross and BlueChoice HealthPlan coverage BlueCross BlueShield of South Carolina is an independent Page 94 licensee of the Blue Cross and Blue Shield Association South Carolina My Insurance Manager FAQ Question registered to use My Insurance Manager Why can t find the claims or other information want on a patient Answer There are several possible reasons e You can only view patient information you submitted under the Tax ID and suffix you used to register For example if you belong to a group practice and filed claims under the group Tax ID you must be registered on My Insurance Manager using that number rather than your individual provider Tax ID e Check your profile to make sure you have entered the appropriate Tax ID one for BlueCross and one for BlueChoice HealthPlan These number
49. e you based on your current participating provider agreement How to Recognize a GRID Program Member On either the front or back of the member s dental only ID card or his or her combined medical dental ID card you should see the word GRID There will also be a customer service number to contact with your benefit or eligibility questions A small number of participating BlueCross and or BlueShield Plans may not immediately update their member ID cards to add the word GRID If a member states he or she has the GRID network but you don t see GRID on his or her card please verify participation Please call the provider service or customer service phone number on the ID card that is listed for dental questions Where to Send Claims for GRID Send claims to the address on the member s ID card Please check the front or back of the card for address information The BlueCross and or BlueShield Plan where the members group is located pays the claims Reimbursement is at your negotiated Participating Dental Agreement fees BlueCross BlueShield of South Carolina is an independent Page 43 licensee of the Blue Cross and Blue Shield Association South Carolina When Did GRID Begin The GRID program became effective January 1 2012 Participating Plans as of 01 01 14 Anthem Blue Cross Anthem Blue Cross and Blue Shield Arkansas BlueCross BlueShield Blue Cross and Blue Shield of Nebraska Blue Cross Blue Shield of Wyoming Bl
50. eShield Plan e Capture all ID card data at the time of service e The member s ID card number is his or her Social Security Number e Be sure all of your system upgrades accommodate the alpha prefix and all characters that follow it e Do not add delete or change the sequence of characters or numbers in a member s ID card number e Make copies of the front and back of the ID card Share this information with your billing staff Sample State Dental Plus ID Card A South Carolina ay South Carolina PUBLIC EMPLOYEE BENEFIT AUTHORITY PEBA STATE OF SOUTH CAROLINA DENTAL PLUS PLAN e un ry F Dental Benefits Program StateSC SouthCarotinaBlues com SUBSCRIBER S FIRST NAME Siate Dental Pan Oniyi Dede ME DAT SUBSCRIBER S LAST NAME Eee n Columbiu 264 3702 Class Preventive No deductible EES 100 up to usual amp customary Member ID ZCS12345678 Cees Basic Yes deductible 80 up 10 usual amp customary Class Hi Prosthete Ves deductible 50 up to usual amp customary To file ciama mai to StueCross BiveShiekd of South Carolina This card is for information only and not PO Box 100300 a guarantee of benefits d a SC 29202 State Dental Plus e sT2 BlueCross BlueShield of South Carolina is an independent Page 47 licensee of the Blue Cross and Blue Shield Association South Carolina Benefits and Eligibility You can access benefits and eligibility for State Dental and Dental Plus members by logging into My Insu
51. ee of the Blue Cross and Blue Shield Association South Carolina You can also check the status of precertification requests at www SouthCarolinaBlues com by logging into My Insurance Manager A precertification is not a guarantee payment of benefits Claim payments are subject to the rules of the plan SHP Vision The SHP offers vision care benefits through the State Vision Plan which is provided through EyeMed Vision Care EyeMed is an independent company that provides vision benefits on behalf of BlueCross BlueShield of South Carolina Providers can contact EyeMed by visiting its website at www eyemedvisioncare com or by calling 877 735 9314 Medical University of South Carolina MUSC State Health Plan The MUSC plan is a State Plan specific to MUSC employees and dependents If a covered member presents a MUSC Plan ID card and the provider is not in the MUSC network then the Standard Plan benefits would apply for the member Sample MUSC State Health Plan ID Card South Carolina 3 PUBLIC EMPLOYEE BENEFIT AUTHORITY Ger South Carolina PEBA SUBSCRIBER S FIRST NAME SUBSCRIBER S LAST NAME Member ID ZCK12345678 f MUSC Health Plan BlueCross BlueShield of South Carolina is an independent Page 22 licensee of the Blue Cross and Blue Shield Association South Carolina SHP Claims You can submit SHP claims electronically using carrier payer code 400 The mailing address for SHP claims is State Health Plan
52. eed eee e eee aaae ee aeee sees etneeaaaeeeeeeeeenee 24 Section 6 BlueCross Medicare Advantage Plans egupsgepsgueeuetarsgeEuEueEgetereguESEeeEEENESEVEREN ENEE ESESEKEREEEEESEdEeEeCeEEEER 25 Medicare Advantage PPO BEE 25 Me diGate EE 25 Medicare E cick chee KEREKERE cid ive NENEN E NEERA OROAR DA ADA ADAADA ADARRERA 25 How to Identify Medicare Advantage Plan Members 26 Medicare Blue and Medicare Blue Saver Service Areas 26 Benefits and EMQIDINIY 032262 ccbescestesades Sesetsestensthecsdietesetensdenctrhr eue Ee S sack een nina Peake ie a eee 26 Balance Bin e e esege eer dedetees egieged ed SE S egtegbE ribet nkri ini riria AERE nET ae 26 Advanced Beneficiary Notice ADN eee e eee t eect ae eee e teeta ae esse eee aaeeeeee tees ee nneecaaeeeeeeetenee 26 OW 10 Fle CAINS ctcccietececescistieciestieteaetes cheacicdricacicird civivisiveciei iva sisi ivi eis iinan eiae SERRE 27 PDO CAS geet eegene deeg eege A A E E eG ee et 28 Section 7 Health Insurance Marketplace Exchange Plans 00 sscceseeeeeeeeeeeeeeeeeeeeeeeeeeeeeeseeeeeeaeeeeaenneeeeeeeaeees 29 Beneit EE 29 CUMS lu te Le BEE 31 Sections BlueCard Propral vectcccnstencnatctets batacetetacctade tatar utes cbate tates tana toninabeecianacs beunegesveuasensneueuisnsasaasnaesecniasett 33 The BlueCard Process IIIUStration cc cceceeeeeeeeeeeenee teeter eee eca a eee eter eee eecaaeeeeee eee tdeeaaaeeeaeeeeeeeeeneecaaeeeeeeenenee 34 How to Identify BlueCard Members 35 Blue
53. enefits and eligibility for Preferred Blue members by logging into My Insurance Manager or using the Voice Response Unit VRU Sample Preferred Blue ID Cards South Carolina H BCBS Plan Name Member Name Member Name Jane Q Doe SUBSCRIBER NAME Member ID Member ID ABC123456789012 XXX123614046483 RxGRP SCB15 RxGRP SCBXX Plan Code 380 PLAN CODE 380 Mammography Network www SouthCarolinaBlues com BlueCross BlueShield of South Carolina is an independent Page 13 licensee of the Blue Cross and Blue Shield Association South Carolina Preferred Blue Mental Health Benefits Contact information for precertification and claim status for mental health services is available on the back of all ID cards Some Preferred Blue policies have mental health benefits through alternative arrangements Therefore it is important that you review members ID cards to determine whom to contact for precertification Most PPO plans have coverage through CBA You can contact CBA through its website at www CompanionBenefitAlternatives com or by calling one of these numbers Companion Benefit Alternatives 803 699 7308 P O Box 100185 800 868 1032 Columbia SC 29202 3185 Outside Columbia Preferred Blue Prescription Drug Plan Caremark is an independent company that provides pharmacy benefits management on behalf of BlueCross Many Preferred Blue members with benefits through our contract with Caremark have a three tier plan with drug card and or mail ser
54. enefits the primary plan reduces when the patient doesn t follow precertification rules such as preadmission emergency admission continued stay reviews and second surgical opinions Personal Injury Protection The secondary plan can reduce its benefits by the amount paid under the personal injury protection PIP portion of a person s automobile insurance policy Medicare Part B Since Medicare Part B is voluntary the secondary plan can reduce its benefits by the amount that Medicare Part B would have paid if the patient had chosen Part B coverage called Phantom B This only applies when the group plan is secondary to Medicare Medicare Carve Out Carve out is a method of calculating benefits when group contracts are secondary to Medicare The State Health Plan uses the carve out method to coordinate benefits The State Health Plan carve out method uses different procedures for calculating secondary benefits on assigned and non assigned Medicare claims Here are the steps for each of the two procedures in detail Medicare Carve Out for Non Assigned Claims We use these steps to determine secondary benefits when providers do not accept Medicare assignment 1 Calculate what the benefits would be in the absence of Medicare Apply deductibles and coinsurance to this calculation 2 Subtract Medicare s payment from normal benefits This gives the dollar amount If the remaining dollar amount is positive then BlueCross will pay th
55. er should give the DME certification form to the participating DME supplier along with his or her ID card DME suppliers should file all claims electronically to BlueCross If we need additional information we will request it For certain DME we may require a precertification to determine medical necessity of continued use after the member has rented the equipment for a specified number of months e g SIDS apnea monitor We will notify the member and the participating DME supplier of the recertification requirements when we approve the initial length of rental We will not pay any claims we receive beyond this approved period without a recertification of medical necessity BlueCross BlueShield of South Carolina is an independent Page 79 licensee of the Blue Cross and Blue Shield Association South Carolina Section 17 Electronic Data Interchange The BlueCross Electronic Data Interchange EDI department facilitates electronic transfer of data services to health care providers and serves as a communication link between your office and BlueCross There are three primary methods available for electronically submitting your claims 1 Direct submission 2 Clearinghouse submission 3 Data entry via the Web using My Insurance Manager Some of the features and benefits of the electronic claim submission are e Shortened reimbursement cycle e Reduced office administrative costs e Decreased claim preparation costs e Verification of receip
56. es a Claim may pend because medical review or additional information is necessary When resolution of a pended claim requires additional information from you we will notify you in writing via your remittance or a letter requesting the additional information Corrected Claims H an adjustment for charges is required resubmit a corrected claim with the correct charges Please do your best to bill correctly the first time and limit the number of corrected claims that you file to us Corrected claims require manual intervention and may decrease your claim adjudication times Appeals If you are dissatisfied with an initial claim determination you can appeal a claim disposition by using the Medical Review Form on www SouthCarolinaBlues com Be sure to include all supporting medical documentation and fax to the appropriate fax number on the bottom of the Medical Review Form BlueCross BlueShield of South Carolina is an independent Page 15 licensee of the Blue Cross and Blue Shield Association South Carolina Federal Employee Program FEP FEP is anon grandfathered plan BlueCross administers for Federal employees and their families FEP uses the Preferred Blue provider network Therefore providers participating in the Preferred Blue network automatically participate with FEP Members can choose from two plan types Basic and Standard Under the Basic option members must use preferred providers in order to receive benefits while with the S
57. esia BlueCross typically reimburses hospital admissions due to pregnancy complications or other non pregnancy related conditions outside of global care BlueCross BlueShield of South Carolina is an independent Page 70 licensee of the Blue Cross and Blue Shield Association South Carolina Accessing Medical Policies BlueCross BlueShield of South Carolina uses medical policies and guidelines to make clinical determinations for members coverage These guidelines are accessible to you on our website www SouthCarolinaBlues com You can also contact our Medical Affairs department if you have questions about our medical policies To access medical policies from the BlueCross homepage Select Provider at the top of the page e Select Education Center on the right side of the page e Under Medical Policies and Clinical Guidelines in the center of the page select Medical Policies e You will be taken to the Medical Policies disclaimer page Once you have read and accepted the disclaimer you will be taken to the listing of Medical Policies e You can then search topics by alphabet or category as well as searching by keywords e f you have questions about medical policies you can contact Medical Affairs by choosing Contact Us at the top of the screen Our clinical staff will review your question and contact you Please note you should submit specific eligibility coverage and claims questions through My Ins
58. ess 1 Address 2 City State ZIP Transactions Vendor Customer s Information If another entity has authorized your business to send or receive transactions on its behalf please provide the entity s name federal Tax Identification Number and service physical address state This is required for all transactions Name Federal Tax State Add Change Remove Identification Number A C R BlueCross BlueShield of South Carolina is an independent Page 90 licensee of the Blue Cross and Blue Shield Association South Carolina If you are a clearinghouse or software vendor and would like to be added to the Certified Vendor list on www SouthCarolinaBlues com please provide this information Website Address URL Salesperson s Name and Telephone If you would like to provide additional contact information please do so here On the description line give a brief explanation or purpose for the additional contact Additional Contact Information 1 Additional Contact Information First Last Name Email ext Fax Bn rs Telephone 2 Additional Contact Information First Last Name Email Telephone _ ext Fax 3 Additional Contact Information First Last Name Email Telephone _ ext Fax BlueCross BlueShield of Sou
59. eview or pre admission review Online Precertification Requests You can request a precertification via My Insurance Manager at www SouthCarolinaBlues com With the Pre Certification Referral feature under Patient Care you can submit precertification requests to BlueCross the State Health Plan BlueEssentials and BlueChoice HealthPlan and some other Blue Plans Precertification requests are not available online for FEP members Visit the Education Center at www SouthCarolinaBlues com to learn more about online precertification requests A precertification is a not guarantee payment of benefits Claim payments are subject to the rules of the plan and eligibility at the time the service is rendered BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association BlueCross BlueShield of South Carolina is an independent Page 59 licensee of the Blue Cross and Blue Shield Association South Carolina National Imaging Associates NIA Some fully insured groups require certain advanced imaging services be precertified by National Imaging Associates NIA when performed and billed in an outpatient or office location NIA is an independent company that manages outpatient imaging and radiology services on behalf of BlueCross BlueCross will retain control over claims adjudication and all medical policies and procedures NIA manages certain outpatient imaging and radiology services We will continue to pay cl
60. f South Carolina is an independent Page 97 licensee of the Blue Cross and Blue Shield Association South Carolina Section 21 Communicating with BlueCross Department Local Toll Free BlueCross Switchboard 800 788 3860 800 288 2227 EDI Help Desk 800 868 2505 Provider Services APS Healthcare 800 221 8699 BlueCard Eligibility 800 676 BLUE 2583 Preauthorization 803 736 5990 800 327 3238 800 334 7287 800 327 3238 800 925 9724 888 376 6544 866 500 7664 800 676 BLUE 2583 800 868 1032 Preferred Blue Federal Employee Program State Health Plan Planned Administrators Inc National Imaging Associates BlueCard Authorization Companion Benefit Alternatives 803 699 3337 www RadMD com Education and Credentialing 800 288 2227 Provider Education Provider Education bcbssc com ext 44730 Tat 800 288 2227 Provider Certification Provider Cert bcbssc com ext 48402 BlueCross BlueShield of South Carolina is an independent Page 98 licensee of the Blue Cross and Blue Shield Association South Carolina PPO Provider Services In and Out of State Ask Provider Services functionality Phone Phone Fax Brian Butler Senior Director Brenda Bethel Director PPO Dental Provider Services Phone Fax Belinda Stokes Manager David Strobel Supervisor 800 868 2510 800 334 2583 Toll Free 803 264 4172 803 264 3235 brian butler bcbss
61. fast free and simple way to talk with a provider services representative after you ve searched online for the answer to a claims status or eligibility question To use STATchat simply log into My Insurance Manager users logging in for the first time will need to create a profile If you still have a question after viewing claims status or eligibility and benefits just click the Ask Provider Services button at the bottom of the page You can submit your inquiry online and receive a response within 24 hours Click the Connect button at the top of the page and you ll soon be speaking to a provider services representative online In fact you will receive priority service and be connected to the next available agent To ensure quick service for all customers please limit yourself to only one issue per call STATchat Available for Precertification When a precertification pends in My Insurance Manager you can now talk to a health care services representative immediately using STATchat through your computer There are also four options in My Insurance Manager for updating your existing authorizations Provide Clinical Information Request Appeal Request Extension and Update Authorization Information After choosing an authorization from any of these options you can use STATchat to speak with a health care services representative immediately To get started you ll need a headset with a microphone or a speaker and microphone Use STATchat now P
62. ferred provider agrees to cooperate fully with the Utilization Review Procedures in the Preferred Blue Professional Agreement e The preferred provider will use other preferred providers for a members care unless medically necessary services supplies or equipment are not available from a preferred provider or in cases of medical emergencies or urgently needed services e The preferred provider agrees to bill promptly and in a manner approved by BlueCross for all services Electronic Claims Submission EMC in the 8371 or 837P HIPAA compliant format is the preferred method of filing If you have any questions about contracting please submit a request by going to the Forms page on our website Provider Fee Allowances The Preferred Blue Professional Agreement states that a preferred provider will accept the fee allowance for covered services defined as the provider s normal charge or the PPO allowance whichever is lower as payment in full Do not bill the member for any amount that exceeds the fee allowance The member is not financially responsible for anything other than applicable copayments coinsurance and deductibles If you have any questions about your fee schedule please contact your contracting specialist BlueCross BlueShield of South Carolina is an independent Page 11 licensee of the Blue Cross and Blue Shield Association South Carolina Section 4 Member Identification Cards When members arrive at your office or facility
63. fication Hysterectomy Synagis Any procedure that may potentially be cosmetic in nature Submit them for review in writing five to seven days before the scheduled procedure Include pictures if appropriate blepharoplasty reduction mammoplasty TMJ surgery etc BlueCross has added special programs for patients undergoing chemotherapy and radiation therapy Please notify us of any patients receiving these treatments You will only need to notify us once fora patient s course of treatment The copayment is waived for e Emergency room services e Physical therapy e Speech therapy e Occupational therapy e Oncology e Dialysis e Routine mammograms e Routine Pap tests e Clinic visits an office visit at an outpatient facility e Electric convulsive therapy e Psychiatric medication management SHP Home Health All home health services require precertification SHP Durable Medical Equipment Precertification is required for e Any purchase or rental of durable medical equipment e Any purchase or rental of durable medical equipment that has a nontherapeutic use or a potentially non therapeutic use e C Pap or Bi Pap machines e Oxygen and equipment for oxygen use outside a hospital setting whether purchased or rented e Any prosthetic appliance or orthopedic brace crutch or lift attached to the brace crutch or lift whether initial or replacement BlueCross BlueShield of South Carolina is an independent Page 21 licens
64. financially responsible for payment other than applicable copayments coinsurance and deductibles You agree to file all FEP claims electronically to BlueCross and should not bill the member for more than the fee allowance BlueCross BlueShield of South Carolina is an independent Page 16 licensee of the Blue Cross and Blue Shield Association South Carolina FEP Prior Authorization FEP Inpatient All inpatient hospitalizations for FEP members require precertification if FEP is primary We must receive inpatient admission authorizations 24 to 48 hours before services Please include this information when requesting a FEP precertification e Patient s name e Identification number e Call back number Failure to get precertification within two business days following the day of an emergency admission or getting authorization after admission on an elective admission will result in a 500 provider penalty FEP Outpatient In general most outpatient procedures for FEP members do not require prior authorization You must get prior authorization for all surgeries related to morbid obesity and congenital anomalies as well as surgeries for oral maxillofacial surgical procedures to correct accidental injuries to jaws cheeks lips tongue roof and floor of mouth Intensity modulated radiation therapy IMRT as well as the BRCA breast cancer and ovarian cancer gene test also require prior authorization FEP Hospice Hospice services do require
65. g the convenience of STATchat Get Details ky _ Attention Dentists Introducing the GRID Our new program lets you see patients from other participating BlueCross and BlueShield Plans at your local Plan reimbursement rate Learn More Ki BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association Page 93 South Carolina Here s how to get started It s easy Just follow the steps as you move through the screens It s secure Secure encryption technology ensures any information you send or receive is completely confidential 1 2 7 Go to www SouthCarolinaBlues com Click on Providers and then log in under My Insurance Manager The first time you use My Insurance Manager you will have to register 3 Register by choosing Create a Profile 4 5 Enter your nine digit Tax ID If you use multiple Tax ID numbers you should register under each Read and accept our terms and conditions one My Insurance Manager uses your Tax ID for BlueCross or BlueChoice HealthPlan for registration Note You must fill in the Tax ID in both spaces The system will verify these numbers and when they match you can register yourself or your practice Create your profile Choose a Username and Password Then fill out the information about your practice Have more than one staff person who could use My Insurance Manager No problem Several peopl
66. gle records vendor among all BlueCross plans streamlines the records request process It helps to eliminate multiple requests from various plans You should only receive requests for records from BlueCross Inovalon or Verisk e Records requests will only come from Verisk for non claim related requests for out of state BlueCross members Verisk is an independent company that coordinates medical records retrieval on behalf of BlueCross e You will continue to receive requests from Inovalon for Medicare Advantage members Inovalon is an independent company that handles clinical documentation services on behalf of BlueCross e You will continue to receive requests from your local BlueCross for claims related issues You or any entity designated for such responsibilities should not charge BlueCross for the creation or submission of medical records As a participating provider your contract states you agree to permit BlueCross BlueChoice or one of our business partners to inspect review and acquire copies of records upon request at no charge We appreciate you working with your vendors to ensure they understand this contractual arrangement to submit the requested records on your behalf without delay or request for payment BlueCross BlueShield of South Carolina is an independent Page 75 licensee of the Blue Cross and Blue Shield Association South Carolina Section 16 Ancillary Health Services Ancillary health providers are licensed and or ce
67. iable for the charges You must refund the payment to the member BlueCross BlueShield of South Carolina is an independent Page 26 licensee of the Blue Cross and Blue Shield Association South Carolina How to File Claims e Use carrier payer code C63 Timely filing is 12 months from date of service Submit claims electronically to BlueCross using Medicare billing guidelines BlueCross will pay all claims for Medicare Advantage plans Payments will not come from a fiscal intermediary or Part B carrier The mailing address for Medicare Advantage products is Medicare Advantage P O Box 100191 Columbia SC 29202 3191 For prompt payment we encourage electronic claims submission You should transmit claims in the HIPAA 837 format under the appropriate payer codes How to File Claims for Supplemental Dental and Vision Benefits Avesis is an independent company that administers routine dental and routine vision benefits on behalf of BlueCross to our Medicare Advantage members Use Avesis carrier payer identification code 86098 for dental claims For routine vision claims use Avesis carrier payer identification code 87098 The mailing address for Avesis is Avesis Claims Center Attn Dental or Vision P O Box 7777 Phoenix AZ 85011 For prompt payment we encourage electronic claims submission You should transmit claims in the HIPAA 837 format under the appropriate payer codes Claim Status You can submit claim status inqui
68. ider performs the test not more than once every seven days or with supporting medical records of an at risk pregnancy 3 Ultrasounds e BlueCross considers the use of an ultrasound to be a medically necessary tool in pregnancies from 10 18 weeks gestation e More than two or repeat ultrasounds during the course of a pregnancy require medical justification 4 Amniocentesis e BlueCross considers this procedure to be performed between the 16 and 20 weeks of gestation to aid in the diagnosis of fetal abnormalities e An infrequent indication for an amniocentesis is for fetal sex determination for pregnancies which are at risk for x linked heredity disorders 5 Multiple births e BlueCross does not consider multiple births a complication of pregnancy when no other complications or risk factors exist If there is a complication during the pregnancy or delivery the provider should file for additional reimbursement consideration using the appropriate modifier indicating complications 6 Tubal ligation during or after delivery e Vaginal delivery BlueCross reimburses at 100 percent of allowed amount e Caesarean delivery BlueCross reimburses at 50 percent of the allowed amount 7 Anesthesia that the attending obstetrician or delivering physician gives e BlueCross will reimburse the attending obstetrician or delivering physician at 50 percent of the allowed amount if he or she performs the insertion and maintenance of epidural anesth
69. ies DME The Plan in whose state the equipment was shipped to or purchased at a retail store e Specialty Pharmacy The Plan in whose state the ordering physician is located If you contract with more than one Plan in a state for the same product type i e PPO or traditional you can file the claim with either Plan BlueCross BlueShield of South Carolina is an independent Page 38 licensee of the Blue Cross and Blue Shield Association South Carolina This claim table demonstrates how to identify the local Plan as defined for ancillary services Provider Type How to File required fields Where to File Example Independent Clinical Laboratory any type of non hospital based laboratory Types of service include but are not limited to Blood and urine samples and analysis etc Referring Provider Field 17 on CMS 1500 Health Insurance Claim Form or Loop 2310A claim level on the 837 Professional Electronic File the claim to the Plan in which state the Specimen was drawn Where the specimen was drawn will be determined by which state the referring provider is located Blood is drawn in lab located in Alabama Blood analysis is done in South Carolina File to BlueCross BlueShield of Alabama Claims for the analysis of a lab must be filed to the Plan in which state the specimen was drawn Durable Home Medical Equipment and Supplies DME Types of service include but
70. il address BlueCross classifies the initial telephone call received before a scheduled inpatient admission or outpatient procedure as a non urgent authorization At the time of the initial call we will need pertinent medical information to complete the authorization If we approve the request we notify the contact person by telephone or fax within one working day of making the decision We provide the authorization number and approved length of stay at this time We send a confirmation letter to the physician hospital and member within 24 hours of the reported admission If we deny the authorization we notify the contact person by telephone within one working day of making the decision We provide the reason for denial at this time The precertification process only evaluates the medical necessity of the inpatient setting for treatment Payment of benefits remains subject to all other member contract or certificate terms conditions exclusions and the patient s eligibility for benefits at the time he or she incurred the expenses Emergency Admission BlueCross requires notification for emergency admissions within 24 hours or the next business day We will request pertinent medical information to document the medical necessity of all emergency admissions Newborn Hospitalizations BlueCross requires precertification for a sick baby or a newborn that the hospital does not discharge with the mother BlueCross BlueShield of South Carolina i
71. indepencent licensee of the Blue Cross AUTOMATIC CLAIMS FILING and Blue Shield Association D Sg www SouthCarolinaBlues com CAREMARK Pharmacy benefits administrator BlueCross BlueShield of South Carolina is an independent Page 53 licensee of the Blue Cross and Blue Shield Association South Carolina Subrogation All BlueCross contracts contain a subrogation clause This clause provides for situations in which a third party is responsible for a patient s medical expenses This provision prevents duplicating payments to the patient and in turn allows BlueCross to keep premiums at a more competitive rate BlueCross will pay the claim and issue a notice of lien This lien will guarantee the recovery of any benefits the member received for medical expenses as a result of the accident Examples of potential subrogation cases include e Automobile accidents a person is injured because of another person s fault e Medical malpractice the doctor or hospital is responsible for injury or illness e Homeowner s the injury is caused by a homeowner s negligence such as steps in need of repair e Slip and fall cases a store fails to clean up liquid on the floor causing someone to slip fall or sustain injury e Product liability case a defective product causes injury Workers Compensation BlueCross considers treatment of an occupational illness or injury a workers compensation service When we receive a clai
72. italization Laboratory services Maternity and newborn care Preventive and wellness services and chronic disease management Mental health and substance use disorder services including behavioral health treatment Pediatric services including oral and vision care Benefit Overview All preventive benefits such as prostate screenings pediatric oral and vision care are covered at 100 percent Women s designated preventive services include but are not limited to mammography screenings and Pap smears at 100 percent The U S Preventive Service Task Force USPSTF defines preventive services Benefits are provided for in network providers only for individual plan members There are no benefits for out of network providers unless it is a true emergency Members may be eligible to receive a federal subsidy This subsidy can be administered as a tax credit in which the member pays the entire premium for the year and then receives the credit when he or she files income taxes It can also be applied as a credit towards the members monthly premium The member would pay a portion of the monthly premium and the federal government would contribute on a monthly basis BlueEssentials Individual Plans The individual exchange products offered by BlueCross are called BlueEssentials and are non grandfathered products BlueEssentials plans operate under an Exclusive Provider Organization EPO which means they use a network of participating doctors hospit
73. its for the level of care carrying the highest allowable charge BlueCross BlueShield of South Carolina is an independent Page 63 licensee of the Blue Cross and Blue Shield Association South Carolina Section 14 Medical Guidelines Multiple Surgeries Multiple surgical procedures are operations physicians perform during the same session When physicians perform multiple procedures at the same time through the same surgical opening or by the same surgical approach the total amount BlueCross covers for such operations or procedures will be the allowable charge for the major covered procedure only If physicians perform two or more operations or procedures at the same time through different surgical openings or by different surgical approaches the total amount BlueCross covers will be the allowable charge for the covered operation or procedure bearing the highest allowance plus one half of the allowable charge for all other covered operations If a service includes a combination of procedures you should use one code rather than reporting each procedure separately If an operation consists of the excision of multiple benign skin lesions BlueCross will pay the total amount it covers according to the allowable charge for the covered procedure bearing the highest allowance 50 percent for the covered procedures bearing the second and third highest allowances 25 percent for the covered procedures bearing the fourth through the eighth highest allow
74. ives credentialing application found on our website Mail or fax completed forms to Companion Benefit Alternatives Inc ATTN Network Representative P O Box 100185 Columbia SC 29202 Fax 803 714 6456 BlueCross BlueShield of South Carolina is an independent Page 10 licensee of the Blue Cross and Blue Shield Association South Carolina Section 3 Provider Obligations Preferred Blue is a line of preferred provider organization PPO health insurance plans we offer The product s benefit structure gives members financial incentives for seeking medical care from a network of preferred providers in South Carolina Each preferred provider s professional agreement lists the contractual responsibilities of both BlueCross and that preferred provider Here is a general summary of the Professional Agreement e The preferred provider will file all claims for Preferred Blue members as well as Exchange Plan members e BlueCross will reimburse the preferred provider for covered services based on the members contract Fee allowances are the lower of the preferred provider s charge for a procedure or the Preferred Blue fee schedule of maximum allowances e The preferred provider will accept BlueCross payment plus any patient copayments coinsurance and deductibles as full reimbursement The preferred provider will not bill the patient for more than his or her applicable patient liability amount not to exceed the fee allowance e The pre
75. lan No employee of BlueCross BlueShield of South Carolina has authority to enlarge or expand the terms of the plan The availability of benefits depends on the patient s coverage and the existence of a contract for plan benefits as of the date of service A loss of coverage as well as contract termination can occur automatically under certain circumstances There will be no benefits available if such circumstances occur BlueCross BlueShield of South Carolina is an independent Page 2 licensee of the Blue Cross and Blue Shield Association South Carolina Table of Contents dree EE EE ege 2 Section 1 General mfOrmation cccceee eee ee scene eee ee nena eee eee ea ene ee eee eee eee eee eee eee 6 el elle ee 6 Provider News and Updates 2 3 uch anki aian hla anda ids EEA ANENE 6 Provider AWN EE 6 Section 2 Provider Information Management ccisicccscssesccsescecaseesescasasscscasaseccassasescassssescasasecsassusescasaseascueveeessrevees 7 File ADDI Cats EE 7 File Application ee EE 7 ChE Elte EE 8 Credentialing Guidelines for Physician Assistants and Nurse Practtoners nna 9 Section 3 Provider ODN Gat OMS iccisecccas scsccacecocacasacasesecdsecacssacasscecesacacasazseacaceeacacacncasacacesasdsisisacasdsasasastsesesosasacees 11 Provider Fee AllOWaNCCS geseet eege dede d e deded degededeg 11 Section 4 Member Identification Card sissccsicccccccssscssececesscesssncssscececscessssvssscacesesssacssevesscscsvssserssendeseseseseree
76. lease visit My Insurance Manager STATchat Firewall Settings If you have a problem connecting to STATchat check the STATchat firewall settings If you see a message about a missing Flash plugin please make sure you have Adobe Flash Player 8 0 or higher installed on your computer Recently STATchat upgraded to User Datagram Protocol UDP from Transmission Control Protocol TCP This upgrade may mean you or your IT administrator will need to make some adjustments If you dont have firewalls within your organization you won have to do anything Our system will automatically convert your protocol when you connect to STATchat If your organization has firewalls your IT administrator will need to configure your network and make it compatible with the new protocol STATchat uses port numbers 1935 8080 8443 and port ranges 19350 65535 Please ensure your firewall allows access to these ports Also make sure these source IP address ranges are opened for the appropriate port Source IP Address Ranges UDP 1935 19350 65535 54 244 93 164 UDP 1935 19350 65535 107 20 176 54 TCP 1935 8080 8443 54 208 165 112 TCP 1935 8080 8443 54 213 218 20 TCP 1935 8080 8443 54 213 218 21 TCP 1935 54 244 93 164 TCP 1935 107 20 176 54 TCP 1935 8080 8443 107 21 16 178 Protocol Port If you continue experiencing problems after these changes please call technical help at 855 229 5720 BlueCross BlueShield o
77. lete or change the sequence of characters or numbers in a member s ID card number e Make copies of the front and back of the ID card Share this information with your billing staff BlueCross BlueShield of South Carolina is an independent Page 12 licensee of the Blue Cross and Blue Shield Association South Carolina Section 5 Benefit Information Benefit Structure Each BlueCross BlueShield of South Carolina insurance plan whether group or individual offers a variety of coverage In addition plans may also have different precertification and mental health requirements Plans may also have separate insurance vendors for certain benefits such as vision or dental Grandfathered versus Non Grandfathered A grandfathered health plan is a plan or policy that had individuals enrolled in it on or before March 23 2010 the day the Affordable Care Act ACA or health care reform law was established A non grandfathered plan is a plan that did not take effect until after March 23 2010 or has not had certain plan changes made to it You can review all of the health care reform plan requirements by visiting our website then selecting Insurance Basics Preferred Blue The PPO product s benefit structure gives members financial incentives for seeking medical care from a network of preferred providers in South Carolina Some Preferred Blue products are considered grandfathered while others are considered non grandfathered You can access b
78. lity of EPA on January 1 will vary depending on the capabilities of each Home Plan Some Home Plans will be fully implemented and have electronic pre service review for many services Others will not yet have implemented electronic pre service review capabilities Claim Submission Always submit BlueCard primary and secondary claims to your local Plan BlueCross BlueShield of South Carolina You should transmit BlueCard claims electronically using the 401 carrier or payer code for BlueCross Be sure to include the members complete ID number when you submit the claim The ID number includes the three character alpha prefix Incorrect or missing alpha prefixes and member ID numbers will delay claims processing For secondary BlueCard claims include the primary payer payment information in the X12N electronic data fields You can file primary and secondary BlueCard claims electronically by logging into My Insurance Manager Once we receive the claim we electronically route it to the member s Home Plan with pricing based on your contractual agreement with us The Home Plan verifies eligibility and determines benefits processes the claim approves payment and sends instructions back to us to pay you on your BlueCross remittance advice In some instances medical records may be required to process a claim Please note we do NOT pay for fees for supplying medical records Please send the requested records so we can expedite the processing of your claim
79. lling Service Check One Professional Health Care Provider C Health Care Plan TT Retail Pharmacy LI Pharmacy Benefit Manager TT Software Vendor TT Other indicate Line of Business _ BlueCross BlueShield of South Carolina Commercial Check One CT PGBA TRICARE Start Date mm dd ccyy End Date ___ mm dd ccyy Required when canceling an account Compression C No Compression C PKZIP O UNIX Check One Protocol C NDM L FTP DIALUP ASYNC DIALUP product Check One C Secure FTP EI VPN C TCPIP via VPN L TCPIP via AGNS Service Address Address 1 Address 2 City State ZIP Billing Address If different from the Service Address Address 1 Address 2 City State ZIP Primary Contact s Information First Last Name Email Telephone __ ext Fax Primary Technical Contact s Information First Last Name Email Telephone __ ex Fax After Hours Technical Contact es Information First Last Name Email Telephone _ ext Fax jl On Call Technical Contact s Information First Last Name Email Telephone ei Fax BlueCross BlueShield of South Carolina is an independent Page 89 licensee of the Blue Cross and Blue Shield Association South Carolina If you use a vendor s software to create ASC X12N transactions you submit to the EDI Gateway please provide the vendor s name and address below and list the transactions Vendor s Information Vendor s Name Addr
80. lth Toolkit If you require members to update this information regularly please keep a copy of the form on file Sending in these forms unsolicited may cause a delay in processing or updating information If you receive a Claim denial requesting the member submit this questionnaire you can then take the completed form and fax or mail to the appropriate location indicated on the form Sending in completed forms to the incorrect area may also cause a delay in processing BlueCross BlueShield of South Carolina is an independent Page 49 licensee of the Blue Cross and Blue Shield Association South Carolina COB Rules e Two policies involved and only one has a COB provision 1 Primary Contract without the COB provision 2 Secondary Contract with the COB provision e Two policies involved Both have a COB provision and the patient is the member 1 Primary The policy that covers the patient as an active employee 2 Secondary The policy that covers the patient as a retired or laid off employee includes COBRA extension e Patient covered under two policies one as a member and the other as a dependent 1 Primary Patient s own policy 2 Secondary Policy under which the patient is a dependent e Patient is a child natural or legally adopted covered under both the father and mother s policy 1 Primary The policy of the parent whose birth month regardless of birth year falls earlier in the year 2 Secondary The policy of the paren
81. lus Plans The dental benefits are divided into four classes diagnostic and preventive services basic dental services prosthodontics and orthodontics We pay covered services under the State Dental Plan based on its Schedule of Dental Procedures and Allowable Charges Dental Plus is a supplement to the State Dental Plan that provides a higher level of reimbursement for dental services covered under the State Dental Plan Members pay the entire premium with no contribution from the State Dental Plus pays up to 1 000 for covered services in each benefit period for each covered member in addition to the 1 000 maximum payment under the State Dental Plan Dental Plus does not pay what the State Dental Plan does not Instead it covers the same procedures and services except orthodontics at the same percentage of coverage as the State Dental Plan The difference is the payment is based on a higher allowance for the covered services How to Identify Dental Plus Plan Members The ID card displays the subscriber s first and last name the identification number including the three digit alpha prefix and the plan name The reverse side of the ID gives a brief summary of benefits the claims mailing address and the customer service telephone number Important facts about the alpha prefix that you should know are e Use of the correct alpha prefix is critical for electronic routing of specific HIPAA transactions to the appropriate BlueCross and or Blu
82. m for services with potential accidental diagnosis we will send an Accident Questionnaire to the member The Accident Questionnaire form is available on our website You can bill the member for these services until the member returns the questionnaire and we have updated the file BlueCross BlueShield of South Carolina is an independent Page 54 licensee of the Blue Cross and Blue Shield Association South Carolina Section 11 Claim Submission Procedure Codes and Guidelines BlueCross uses physicians Current Procedural Terminology CPT a systematic listing and coding of procedures and services performed by providers for processing claims A five digit code identifies each procedure or service Because medical nomenclature and procedural coding are rapidly changing fields certain codes may be added modified or deleted each year Please make sure your office uses the current edition of the codebook when filing claims BlueCross will reject claims containing invalid codes at the EDI Gateway and will return paper claims to the providers Diagnosis and Procedure Coding The International Classification of Diseases 9th Revision Clinical Modifications ICD 9 CM is the basis of diagnosis and procedure coding at BlueCross This system is composed of three volumes e Volume 1 Diseases Tabular List e Volume 2 Diseases Alphabetic Index e Volume 3 Procedures Tabular List and Alphabetic Index This system classifies diagnoses by three digi
83. medical purpose DME is used to treat any illness or injury and is appropriate for home use BlueCross offers benefits for DME when it meets all these criteria e The equipment provides therapeutic benefit to a patient in need due to certain medical conditions and or illnesses e A physician prescribes the equipment e The equipment does not serve primarily as a comfort convenience or hygienic item or safety item e The equipment does not have significant non medical uses environmental control equipment As a general rule the patient must be capable of operating the equipment unassisted Equipment that is for the convenience of a caregiver is not eligible for coverage BlueCross will however cover a hospital bed for a quadriplegic patient requiring body positioning This exception meets the medical necessity requirement but not the criteria for operating the equipment unassisted We do not offer DME benefits for repair or maintenance of rented equipment The repair or maintenance of rented DME is the responsibility of the participating DME supplier at no additional charge to the member The member is responsible for DME repair and maintenance of purchased equipment subject to warranty provisions or medical necessity BlueCross BlueShield of South Carolina is an independent Page 77 licensee of the Blue Cross and Blue Shield Association South Carolina For purchased DME the participating DME supplier must provide a two year warranty
84. members state of South Carolina employees and federal employees When submitting review requests please use this form as a cover to all attachments Be sure to complete or check each section as appropriate When you submit a second level appeal we require additional information If you do not submit new or additional documentation we will uphold the denial Patient Information Patient s Name Identification Number Type of Plan Check only one II State Health TI Federal Employee Cl Group amp Individual Preferred Blue 0 BlueCard Provider Information Email Address Provider s Name Provider Number Phone Number Provider s Address Contact Person Signature of Person Requesting Review Appeal 1 level Review D 2 4 level ICH Appeal check one Attach copy of 1 review denial for Appeal Claim Number Date of Service Description of Request Attachments Please attach all documentation you would like us to consider in the review appeal ICH Remittance Advice 0 History and Physical ICH Operative Report Q Office Notes ICH Pathology Report ICH Hospital Progress Notes ICH Radiology Report II Laboratory Report O Other Do not attach claim Fax or mail to the appropriate address STATE HEALTH PLAN STATE HEALTH PLAN AX B10 ZCS ALPHA PREFIX ATTN MEDICAL APPEALS P O BOX 100605 COLUMBIA SC 29260 FAX 803 264 4204 FEDERAL EMPLOYEE PROGRAM AX B05 ATTN MEDICAL APPEAL
85. nagement customer and provider services and medical management Sample State Health Plan ID Cards e ot ena PUBLIC EMPLOYEE BENEFIT AUTHORITE ea GP sour Caredina PEBA milh Land PUBLIC EMPLOYEE BENEFIT VTT cay South Cancd ina SUBSCRIBER S FIRST NAME SUBSCRIBER S LAST NAME Member IO 2 512345678 Smeken PPO You can access current eligibility and benefit information deductible amounts coinsurance percentages and claim status by logging into My Insurance Manager at www SouthCarolinaBlues com You can also access member benefit booklets on the SHP employee website at https StateSC SouthCarolinaBlues com web public statesc SUBSCRIBER S FIRST NAME SUBSCRIBER S LAST NAME MemberID 212345678 satesuvogsiea PPO T The SHP consists of two separate plans the Savings Plan and the Standard Plan You can view a member s SHP benefit booklet by logging into My Insurance Manager on our website Other SHP Information SHP Retiree Coverage State retirees can elect two types of coverage the Standard Plan and the Medicare Supplement Plan The ID cards for both of these plans read as State Health Plan Retirees covered under the Standard Plan use the carve out method to coordinate benefits when Medicare is primary over the State Plan With carve out BlueCross uses different procedures for calculating secondary benefits on assigned and non assigned Medicare claims A detailed explanation of the two proced
86. ndependent Page 45 licensee of the Blue Cross and Blue Shield Association South Carolina COB The member s medical coverage is always primary while FEP BlueDental is secondary Submit all claims to the primary medical plan first Refer to the back of the members medical ID card for submission Submit pre estimates of benefits directly to FEP BlueDental Upon completion of the dental care submit the claim to the primary medical plan Service Benefit Plan FEP Medical Member Submit claims to the local BlueCross BlueShield Plan Primary payment will be sent to you and then FEP Medical will forward the claim along with the primary payment amount to FEP BlueDental The primary benefit will be coordinated on the claim received from the medical carrier and upon completion of COB FEP BlueDental will send the secondary payment to you Reconsiderations Claim Dispute If you and your FEP BlueDental patient disagree with the initial decision of how dental services were processed please encourage your FEP BlueDental patient to refer to his or her FEP BlueDental Brochure on how to submit a reconsideration Send reconsiderations or claim disputes to FEP BlueDental Claims Appeals P O Box 551 Minneapolis MN 55440 0551 BlueCross BlueShield of South Carolina is an independent Page 46 licensee of the Blue Cross and Blue Shield Association South Carolina State Dental and Dental Plus Plans BlueCross administers the State Dental and Dental P
87. next page e The Trading Partner Agreement The purpose of the EDIG Trading Partner Enrollment Form is to enroll providers software vendors clearinghouses and billing services as trading partners and recipients of electronic data It is important you follow the instructions and complete all the required information We will return incomplete forms to the applicant which could delay the enrollment process You can find the enrollment form at the HIPAA Critical Center or in the Appendix of the EDI Gateway Technical Communications User s Manual If you are a prospective BlueCross or BlueChoice HealthPlan trading partner print and mail a hard copy of the completed Trading Partner Agreement to BlueCross BlueShield of South Carolina Technology Support Center EDI Enrollment I 20 at Alpine Road AA E05 Columbia SC 29219 We will acknowledge our EDI Gateway s receipt of your completed enrollment form via email within three business days and will include your Trading Partner ID BlueCross BlueShield of South Carolina is an independent Page 88 licensee of the Blue Cross and Blue Shield Association South Carolina BlueCross BlueShield of South Carolina EDIG Trading Partner Enrollment Form ASC X12N Transactions Date Action Requested _ New Trading Partner ID Check One 4 Change TT Cancel Trading Partner s Name Trading Partner ID Federal Tax ID Type of Business Institutional Health Care Provider Clearinghouse O Bi
88. ng the Precertification section of www southCarolinaBlues com BlueCross BlueShield of South Carolina is an independent Page 60 licensee of the Blue Cross and Blue Shield Association South Carolina Preadmission Authorization Program The Preadmission Authorization Program reviews and authorizes hospital admission before hospitalization to make sure the service is medically necessary appropriate and in accordance with the member s group contract You can request precertification for BlueCross BlueChoice HealthPlan and State Health Plan members by logging into My Insurance Manager Contact FEP to get precertification for FEP members at 803 264 0258 fax or 800 327 3238 We resolve a high percentage of Web requests immediately and provide precertification numbers instantly If you do not have access to the Web refer to the member s ID card to get the phone number for preadmission authorization We will request this information e Patient s nmember s name current address date of birth BlueCross ID number and relationship of the patient to the member Provider s name address and telephone number Name of the hospital to which you plan to admit the patient Anticipated admission date Requested length of stay Admitting diagnosis major procedures plan of treatment medical justification for inpatient admission and complications or other factors requiring the inpatient setting e Callers name phone number fax number and ema
89. nt for risk factors for CRNAs or anesthesiologist supervision of CRNAs even if providers report these separately If a CRNA inserts the needle under the direct supervision of an anesthesiologist the anesthesiologist may bill a QK modifier BlueCross BlueShield of South Carolina is an independent Page 66 licensee of the Blue Cross and Blue Shield Association South Carolina Conscious Sedation Physicians use sedation with or without analgesia to achieve a medically controlled state of depressed consciousness while maintaining the patient s airway protective reflexes and ability to respond to stimulation or verbal commands Benefits for this service are included in the benefits BlueCross provides for medical care consultations or surgical care including the pre and postoperative care Monitoring of IV sedation by an anesthesiologist for gastrointestinal endoscopy arteriograms CT scans MRIs cardiac catheterizations and PTCA may be medically necessary for children acutely agitated patients or in some cases acutely ill patients who cannot have the procedure without sedation Exceptions may be made for CT scans and MRIs for agitated patients Examples include but are not limited to patients With organic brain disease With senile dementia With delirium With claustrophobia Who are uncooperative mentally retarded In the case of cardiac catheterization and PTCA the catherization lab setting provides monitoring availability An
90. ociation South Carolina Benefits and Eligibility You can access benefits in network and out of network and eligibility for commercial dental plan members by logging into My Insurance Manager or by calling the Provider Services VRU at 800 222 7156 Columbia Service Center or 800 922 1185 Greenville Service Center How to File Claims for Commercial Dental Plans The mailing address for Commercial dental claim forms is on the back of the member s ID card When submitting a hard copy claim use the standard 2012 American Dental Association ADA Claim form e Use carrier payer code 38520 e Timely filing is 12 months from the date of service e Submit claims electronically to BlueCross BlueShield of South Carolina in the HIPAA 837D format This is our preferred method of claim submission for all providers Dental GRID Several BlueCross and BlueShield Plans around the nation have developed a program that enables dentists to see patients from other participating BlueCross and BlueShield Plans at their local Plan reimbursement levels We call this program the national Dental GRID What This Means for You More patients will likely turn to your dental office for their dental care This is because you will be in network for patients who are members of BlueCross and BlueShield groups based in other states It will not change your reimbursement levels or participating provider agreement in any way We will continue to reimburs
91. ority of physicians and other providers but not all You should assign responsibility for ensuring compliance with the transactions and code sets to a specific person within your office who can work with the information systems vendors payers and clearinghouses as applicable Also you should establish a process to monitor the status of new regulations and changes to comply with them as they become effective BlueCross BlueShield of South Carolina is an independent Page 85 licensee of the Blue Cross and Blue Shield Association South Carolina HIPAA Transactions e 270 271 Benefits and Eligibility e 276 277 Claim Status e 278 Review e 834 Membership e 835 Remittance e 837 P D Claim submission 270 Health Care Eligibility Benefit Inquiry 271 Health Care Eligibility Benefit Response 276 Health Care Claims Status Request 277 Health Care Claims Status Response 278 Health Care Services Review Request for Review and Response for prior authorizations and referral authorizations 835 Health Care Claim Payment Advice Commonly called Electronic Remittance Advice ERA 837 Health Care Claim The 837 Professional version replaces the HCFA 1500 or NSF electronic format the 837 Institutional version replaces the UB 92 and the 837 Dental version is for dental claims BlueCross BlueShield of South Carolina is an independent Page 86 licensee of the Blue Cross
92. ormation and the review denial letter to the form Fax or mail this information to the appropriate service area It generally takes BlueCross 30 days to complete appeals and initiate claim adjustments or generate letters of second denial to providers BlueCross BlueShield of South Carolina is an independent Page 72 licensee of the Blue Cross and Blue Shield Association South Carolina Inappropriate Reviews There are some instances when providers file reviews or appeals for reasons other than claim denials We call these inappropriate reviews Here are some examples of inappropriate use of the review and appeal processes e Checking claim status Get claim status by using My Insurance Manager or the VRU e Sending a claim follow up letter tracer claim patient account report or corrected claim BlueCross will deny any claims you submit after the originals as duplicates File corrected claims electronically through the HIPAA X12N format or via My Insurance Manager e The procedure or service is not a covered benefit for the patient under his or her contract A request for medical review will not alter the coverage If your office consistently files medical reviews for items that are not appropriate for review an education specialist may initiate a training session to discuss proper procedures Levels of Appeals Step 1 The initial decision by BlueCross When BlueCross makes its initial decision it is giving its inte
93. ou can print the Other Insurance form from www southCarolinaBlues com and give it to your patient if he or she does not have access to our website BlueCross BlueShield of South Carolina is an independent Page 48 licensee of the Blue Cross and Blue Shield Association South Carolina Section 10 Other Carrier Liabili One method of controlling health insurance costs is called Other Carrier Liability OCL We use OCL when the payment for a member s medical expenses is the responsibility of more than one third party payer Examples of third party payers include group health insurance plans Medicare workers compensation and subrogation We define and explain the four rules of OCL here COB Calculating payments between the primary and secondary plans is called of COB COB is a contractual provision of our group contracts The COB rules determine which insurance carrier will be primary and pay regular benefits They also determine which insurance carrier will be secondary and pay the remaining balance not to exceed the policy limit When filing for patients covered by two or more health plans bill the primary carrier first When you receive payment file the claim with the secondary information electronically to the secondary carrier and then to the tertiary third carrier if applicable The Other Health and Dental Coverage Questionnaire form is available on our website Members can also update this information when they log into My Hea
94. ovider Number 52 Medicare Non Automated Cross Over Gysiem ttn nnnasnn nnn nnnnnnsnnnnn nnn nnn nennt 53 Medicare Automated Cross Over System cccceceeeeeeeecnneeeeeeeeeeeceaaaeeeeeeeeeeeecaaaaeeeeeeeeeeeeeaaaeeeaeeeeeeeeeeeeeaaaes 53 leie re TEE 54 Workers Compensation vvvsesisietenctecces iytysecnceceeecresenceenceecencessenseencteceres sovassnraueesenssbeeddesvduertecetesedesudeentecateraterwits 54 Section 11 Claim SUbDMUISSION ii sssccscesssecsceccsessdnccsusedaaaseneteansedeceansadedeandadaduaudee acusaseeneuaus caduecccasaxecccasasexcuaaaeeccaatee 55 Procedure Codes and Guidelines AAA 55 Diagnosis and Procedure Coding 55 lee EE 55 UNM CAINS E 55 el UE 56 TAO Une RTE 56 Provider Net segguetktrteeg eeg eegeEEeegbeEEeEgeEEEeESEEEERSEEeEEEeEEEeEEE E SegeEETERROEE EENS VALAA A ANAE AANGAAN AANE es 56 Le Une E 56 Section 12 Remittance ACViCC escccceeeeeeeeeee eee ee seen eee eea an eee sees ee eeaea eee aeaag eee eeeae nnmnnn nnmnnn nnnm nnnm 57 Remittance e 57 My Remit M t vciitiaiciiiceteca tee ite acta ee eS aE na aA e KaKa ALAE TA AAA AAAA UAN GAA daN A ARAN Aai 58 Section 13 Medical Management ssseSRRSSREEEEEERRRRRERRREEEEEEEERRREERREEEEEEEEEREEEERREEEEEEEEERREERREEEEEEENEERREEEEEEEEEEREEERREEEEE EN 59 Online Precertification Heouests 59 National Imaging Associates NIA eee e eet e ene e etter eee a deere eee aaaee seer eet edeccaaaeeeeeeeeeeeeeaaaes 60 Preadmission Authorization Program 61 Emergency A
95. ox 100185 800 868 1032 Columbia SC 29202 3185 Outside Columbia Prescription Drug Plan Members have drug coverage through Caremark They have a four tier plan with either a drug card and or mail service benefits You can download the Preferred Drug List through our website www sSouthCarolinaBlues com Benefits and Eligibility Always verify coverage for members as eligibility may change based on the premium status You can quickly get the most current member eligibility and benefit information by using My Insurance Manager on our website You can also call the Provider Services VRU at 800 868 2510 Precertification Certain categories of benefits require precertification Failure to get preauthorization may result in us denying benefits Precertification is not a guarantee that we will cover the service For precertification requirements verify benefits and eligibility through My Insurance Manager Once you have verified precertification requirements you can initiate the precertification request in My Insurance Manager Premium Delinquencies Members who do not have a federal subsidy do not have a delinquency grace period We will deny claims immediately upon delinquency Members who have an FFM policy and receive a federal subsidy have a three month grace period During the first month of delinquency we will process all claims and apply benefits accordingly During the second and third month of delinquency claims will pend until the mem
96. pend because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BlueCross will notify you in writing via your remittance or a letter requesting the additional information Corrected Claims If an adjustment for charges is required resubmit a corrected claim with the correct charges Please do your best to bill correctly the first time and limit the number of corrected claims that you file to us Corrected claims require manual intervention and may decrease your claim adjudication times Appeals If you are dissatisfied with an initial claim determination you can appeal a claim disposition by using the Medical Review Form on www SouthCarolinaBlues com Be sure to include all supporting medical documentation and fax to the appropriate fax number on the bottom of the Medical Review Form BlueCross BlueShield of South Carolina is an independent Page 18 licensee of the Blue Cross and Blue Shield Association South Carolina State Health Plan SHP SHP is a self insured grandfathered medical plan available for the state of South Carolina employees and their families It offers valuable medical coverage if a member becomes sick or injured It also offers some limited services for routine care The South Carolina Public Employee Benefit Authority PEBA determines the benefits develops reimbursements and governs the SHP BlueCross administers the SHP providing claims ma
97. prior authorization ee Fax 803 264 0258 FEP Precertification Voice 800 327 3238 FEP Durable Medical Equipment DME FEP does not require precertification for any DME products but they are subject to medical necessity and individual contract benefit limitations We do require a Certificate of Medical Necessity CMN Supplies are not reimbursable when the member is renting the equipment The preferred method of submission is electronic for all DME claims FEP Claims You can submit FEP claims electronically using carrier payer code 402 The mailing address for FEP claims is Federal Employee Program P O Box 600601 Columbia SC 29260 For prompt payment we encourage electronic claims submission You should transmit claims in the HIPAA 837 format under the appropriate payer codes Claim Status You can submit claim status inquiries by visiting www SouthCarolinaBlues com and logging into My Insurance Manager You can also access claim status through the VRU by calling 888 930 2345 BlueCross BlueShield of South Carolina is an independent Page 17 licensee of the Blue Cross and Blue Shield Association South Carolina Claim Payment If you do not receive payment for a claim it is not necessary to resubmit the claim This confuses members because they receive multiple EOBs You should check claim status by either calling our VRU at 888 930 2345 or in My Insurance Manager at www SouthCarolinaBlues com In some cases a claim may
98. rance Manager or by calling State Dental Customer Services at 888 214 6230 toll free or 803 264 3702 in Columbia How to File State Dental and Dental Plus Claims e Use carrier payer code 38520 e Timely filing is 24 months from the date of service e Submit claims electronically to BlueCross in the HIPAA 837 format under the appropriate carrier code This is our preferred method of claim submission for all providers When submitting a hard copy claim use the 2012 ADA State Claim form which can be found at https StateSC SouthCarolinaBlues com in the Publications and Forms section The mailing address for State Dental claim forms is BlueCross BlueShield of South Carolina State Dental Claims P O Box 100300 Columbia SC 29202 3300 Claim Status You can submit claim status inquiries by visiting www SouthCarolinaBlues com and logging into My Insurance Manager You can also access claim status through the State Dental VRU by calling 888 214 6320 toll free or 803 264 3702 in Columbia Other Health Dental Insurance Questionnaire Dental providers can assist members who need to update their Other Health Dental Insurance OHI information We require our members to update this information yearly You can make it easy by giving members computer access right in your office Ask them to log into My Health Toolkit and update their information Have the member follow a link to the Other Health Dental Insurance Questionnaire Or y
99. re respiratory or cardiac disease p 5 Add three time units when the patient is not expected to survive for 24 hours with or without the operation such as multiple severe trauma or severe head injury Other Anesthesia Maternity Epidural Anesthesia e Global allowance with no consideration of time units Limited to practitioner who personally inserts the epidural needle File AA or QZ modifiers e No separate reimbursement for monitoring or supervising Stand By Anesthesia BlueCross provides benefits if the anesthesiologist offers the personal patient care normally provided when administering anesthesia e g examines patient connects monitoring lines personally monitors patient during operative procedure but does not actually administer the anesthesia unless required We may reimburse the anesthesiologist for both the procedure and time File claims for stand by anesthesia using the appropriate anesthesia code anesthesia modifier and time units Qualifying Circumstances Physicians provide many anesthesia services under particularly difficult circumstances depending on factors such as extraordinary condition of patient notable operative conditions and unusual risk factors These circumstances significantly impact the character of the anesthesia service the physician provides BlueCross may only reimburse qualifying codes if the physician administers the anesthesia personally There will be no separate reimburseme
100. rent s plan does not cover dependents Covered individuals each have their own ID cards Sample BlueEssentials ID Cards BlueCross BlueShield of South Carolina is an independent Page 30 licensee of the Blue Cross and Blue Shield Association South Carolina Small Group Exchange Plans The small group exchange products BlueCross offers are non grandfathered products The small group private exchange products use the BlueCross Preferred Blue network How to Identify Small Group Exchange Plan Members Group product lines access the broad commercial BlueCross Network Preferred Blue New alpha prefixes are ZCV and ZCR These ID cards also have Preferred Blue Network on the cards The suitcase in the lower right indicates the network that members access when out of state Sample Small Group Exchange Cards ltz aa 9 South Carolina South Carolina Member Name Member Name Preferred Blue Network NAME NAME Member ID Member ID RxBIN RxGRP Plan Code Plan Code Mammography Network Mammography Network www SouthCarolinaBlues com PPO Wwww SouthCarolinaBlues com BlueCross BlueShield of South Carolina is an independent Page 31 licensee of the Blue Cross and Blue Shield Association South Carolina Other Information Mental Health You should get treatment plans through CBA You can visit www CompanionBenefitAlternatives com or call one of these numbers Companion Benefit Alternatives 803 699 7308 P O B
101. ries by visiting www SouthCarolinaBlues com and logging into My Insurance Manager You can also access claim status through the VRU by calling 800 868 2510 Claim Payment If you do not receive payment for a claim it is not necessary to resubmit the claim This confuses members because they receive multiple EOBs You should check claim status by either calling our VRU at 800 868 2510 or using My Insurance Manager at www SouthCarolinaBlues com In some cases a claim may pend because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BlueCross will notify you in writing via your remittance or a letter requesting the additional information BlueCross BlueShield of South Carolina is an independent Page 27 licensee of the Blue Cross and Blue Shield Association South Carolina Corrected Claims H an adjustment for charges is required resubmit a corrected claim with the correct charges Please do your best to bill correctly the first time and limit the number of corrected claims that you file to us Corrected claims require manual intervention and may decrease your claim adjudication times Appeals If you are dissatisfied with an initial claim determination you can appeal a claim disposition by using the Medical Review Form on www SouthCarolinaBlues com Be sure to include all supporting medical documentation and fax to the appropriate fax number on the bottom of
102. rization to Bill form page 11 of the SCUCA application NPI NPPES confirmation letter or email A signed contract signature page for each network to which you wish to apply Note You only need to submit one SCUCA application regardless of the number of networks for which you are applying Please email your completed application and documentation to provider cert bcbssc com or fax to 803 264 4795 BlueCross BlueShield of South Carolina is an independent Page 8 licensee of the Blue Cross and Blue Shield Association South Carolina Credentialing Guidelines for Physician Assistants and Nurse Practitioners Physician Assistants PA BlueCross credentials physician assistants PAs PAs can choose to file claims for medical and laboratory services they provide in the office under their legacy identifiers or rendering NPls They can also bill under the supervising doctor s legacy identification number or NPI Our policies do not cover a PA as an assistant at surgery Only MDs are covered as assistant surgeons if medically necessary If a PA is assisting during surgery the PA must bill as the rendering provider using an AS modifier Nurse Practitioners NP BlueCross must credential nurse practitioners NPs who are not under direct supervision of a doctor NPs must submit claims under their NPI numbers They can also bill under the supervising doctor s NPI number BlueCross does not credential these specialties Associate Counselor Dia
103. rom the date of receipt of the ALJ hearing decision Level 5 Federal Court Review If the provider disagrees with the decision the Departmental Appeals Board made in appeal level 4 the federal court can review the case The time limit for filing the appeal request is 60 days from date of receipt of DAB decision or declination of review by DAB The dollar value of the contested benefit must be at least 1 350 in controversy For additional information about Medicare Advantage coverage please refer to the Medicare Advantage Office Administrative Manual available on our website BlueCross BlueShield of South Carolina is an independent Page 28 licensee of the Blue Cross and Blue Shield Association South Carolina Section 7 Health Insurance Marketplace Exchange Plans Health plans in the individual and small group markets are offered through the Federally Facilitated Marketplace FFM and private marketplaces The federal government manages the FFM and insurance companies manage private marketplaces Plans are available to both individuals that may be uninsured underinsured or otherwise eligible for federal subsidies and small businesses Non grandfathered health plans within the Health Insurance Marketplace exchanges must offer a core package of items and services called essential health benefits Ambulatory patient services Prescription drugs Emergency services Habilitative and rehabilitative services and devices Hosp
104. ross and Blue Shield Association South Carolina Some PPO groups may have precertification requirements that differ from the previous list i e some groups require prior notification for physical soeech and occupational therapies Check for group specific precertification requirements before providing services and request a precertification via My Insurance Manager The system will let you know if a precertification is not required The precertification requirements are on our website in the Education Center Preferred Blue Claims You can submit Preferred Blue claims electronically using carrier payer code 401 The mailing address for Preferred Blue claims is BlueCross BlueShield of South Carolina Columbia Service Center P O Box 100300 Columbia SC 29202 For prompt payment we encourage electronic claims submission You should transmit claims in the HIPAA 837 format under the appropriate payer codes Claim Status You can submit claim status inquiries by visiting www SouthCarolinaBlues com and logging into My Insurance Manager You can also access claim status through the VRU by calling 800 868 2510 Claim Payment If you do not receive payment for a claim it is not necessary to resubmit the claim This confuses members because they receive multiple Explanations of Benefits EOBs You should check claim status by either calling our VRU at 800 868 2510 or using My Insurance Manager at www SouthCarolinaBlues com In some cas
105. ross will reimburse 150 percent of the allowable for covered procedures Anesthesia BlueCross requires anesthesiologists and CRNAs to file claims using CPT anesthesia codes We cover general anesthesia services when the operating physician requests them and a nurse anesthetist or physician other than the operating physician performs them for covered surgical services We cover anesthetic or sedation procedures the operating physician or an advanced practice registered nurse performs as a part of the surgical or diagnostic procedure We consider local anesthesia to be an integral part of the surgical procedure and do not provide additional benefits We recognize these modifiers Anesthesiologist Modifiers e AA Anesthesia services an anesthesiologist personally performs e AD Medical supervision by a physician more than four concurrent anesthesia procedures e QK Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals e QY Medical direction of one certified registered nurse anesthetist CRNA by an anesthesiologist CRNA Modifiers e QX CRNA service with medical direction by a physician e QZ CRNA service without medical direction by a physician Monitored Anesthesia Care Modifiers BlueCross may reimburse for modifiers QS G8 and G9 if a physician personally performs the procedure modifier AA and if the procedure meets medical necessity criteria We will not reimburse modifiers QK
106. rpretation of how the members covered benefits and services apply to the specific situation Step 2 Appealing the initial decision by BlueCross If a physician or physician group disagrees with the decision made in Step 1 it can appeal a claim disposition by using the Medical Review Form Be sure to include all supporting medical documentation and fax to the appropriate fax number on the bottom of the Medical Review Form After reviewing the reconsideration BlueCross will decide whether the initial decision should be affirmed dismissed or reversed Step 3 Request for a review by an independent review organization If the claim has gone through the reconsideration process and the physician or physician group is still dissatisfied it can request an independent review organization to review the claim The organization will review the request and decide to affirm dismiss or reverse the original decision BlueCross BlueShield of South Carolina is an independent Page 73 licensee of the Blue Cross and Blue Shield Association South Carolina You can find the Medical Review form in the Providers section of our website Just click Forms then Provider Appeals and Medical Review SAMPLE South Carolina BlueCross BlueShield of South Carolina is an independent l of the Blue Cross and Blue Shield Association To request claims review please complete this information for BlueCross BlueShield of South Carolina members including Preferred Blue
107. rrier Check the membere ID card for the correct Blue Plan name e Include the alpha prefix as part of the member identification number The alpha prefix is critical for confirming membership and coverage and key to facilitating prompt payments e When you receive the remittance advice from the Medicare intermediary look to see if the claim has been automatically forwarded crossed over to the Blue Plan If the Medicare claim has crossed over to the appropriate Blue Plan DO NOT resubmit the claim to BlueCross Wait 30 days to receive the payment from the Blue Plan before sending another claim Sending another claim slows down the claim payment process and creates confusion for the member If the Medicare claim was not crossed over submit the claim along with the Medicare remittance advice to BlueCross Note Processed claims submitted to the Medicare intermediary will be crossed over to the Blue Plan within 14 business days This means that the Medicare intermediary will be releasing the claim to the Blue Plan for cross over processing about the same time you receive the Medicare remittance advice As a result it may take an additional 14 30 business days for you to receive payment from the Blue Plan BlueCard Contacts and Resources BlueCard Contacts and Resources BlueCard Eligibility 800 676 BLUE 2583 800 810 BLUE 2583 www SouthCarolinaBlues com Select Find a Provider BlueCard Access Line Provider Search www
108. rtified health care professionals other than physicians or hospitals These can include dialysis centers durable medical equipment suppliers ambulatory surgical centers diagnostic centers and any other health care provider organization or institution BlueCross recognizes Ambulatory Surgery Centers Ambulatory surgery centers should file claims electronically to BlueCross in the HIPAA compliant 8371 UB 04 format File with the appropriate bill type revenue code and CPT codes You will not need the SG modifier on these institutional forms Prior authorization follows each specific group requirement Dialysis File electronically using the HIPAA compliant 8371 UB 04 e File dialysis claims using the appropriate CPT 4 codes e Use the service unit s field to indicate the number of treatments within the dates of service that appear on the claim e ltemize all other billed charges for services or products and include the appropriate HCPCS code on the claim Home Health Services Home health providers should file claims electronically to BlueCross in the HIPAA compliant 8371 UB 04 format File with the appropriate bill type and revenue code for the type of treatment as a single line item You must get prior authorization for all home health services BlueCross BlueShield of South Carolina is an independent Page 76 licensee of the Blue Cross and Blue Shield Association South Carolina Hospice Bill hospice care electronicall
109. s BlueCross BlueShield of South Carolina is an independent Page 37 licensee of the Blue Cross and Blue Shield Association South Carolina Exceptions to BlueCard Claim Submissions Exceptions may occasionally arise when you must file the claim directly to the member s Plan Here are some of those exceptions e You contract with the member s Blue Plan for example in a contiguous county e The member ID card does not include an alpha prefix e A separate vendor processes services which requires direct filing e g APS Healthcare or the State Health Plan Claim Status Always check the status of your claims through your local BlueCross Plan Visit www SouthCarolinaBlues com and log into My Insurance Manager to check the status of your claim We send claim status inquiries you submit via the Web directly to the member s Home Plan so we can send you a response immediately Ancillary Claims Generally you should file claims directly to BlueCross There are circumstances however when claims filing directions will differ based on the type of provider and service Ancillary providers are independent clinical laboratory durable nome medical equipment and supplies and specialty pharmacy providers The local Blue Plan as defined for ancillary services is e Independent Clinical Laboratory Lab The Plan in whose state the specimen was drawn based on the location of the referring provider e Durable Home Medical Equipment and Suppl
110. s an independent Page 61 licensee of the Blue Cross and Blue Shield Association South Carolina Notification of Admission Status Change Occasionally it may be necessary to change or cancel an admission or adjust the anticipated length of stay When a change in the nature duration or reason s for an authorized admission occurs you should notify the authorization unit of the change What Happens When an Admission Review Isn t Done Your patient or facility may receive a penalty such as denial of room and board charges BlueCross may reduce the member s benefits additional copayment deductible BlueCross may delay payment for the claim to determine medical necessity BlueCross may need medical records to review the claim Case Management Case management is a free service BlueCross offers to all Preferred Blue and State Health Plan members on a voluntary basis to help them and their families plan coordinate and evaluate the options and services necessary to help deal with the complex health care delivery system BlueCross case managers are registered nurses who are knowledgeable in the care of patients and work in cooperation with all the health care providers involved in a patient s care When we identify a member as someone who may benefit from case management services a case manager will call the patient explain the benefits of the program and ask if he or she is interested in participating Or if you feel that a patient nee
111. s may or may not be the same e You can only view claims information for the services your practice offers not for the services of another provider or practice Question How can we use My Insurance Manager for my entire group practice Answer You can create multiple usernames and passwords for the same Tax ID number The profile administrator will manage these usernames Question Is My Insurance Manager secure Answer Yes You can only register if you have a valid Tax ID number on our systems We verify this number against our internal systems With our profile administrator process the office administrator will have the ability to add and remove access to all user accounts thus keeping your information secure BlueCross BlueShield of South Carolina is an independent Page 95 licensee of the Blue Cross and Blue Shield Association South Carolina Section 20 PPO Voice Response Unit and STATchat VRU Need to know the status of a claim Looking for eligibility or benefits for a patient Call our VRU line The VRU is available 24 hours a day seven days a week using a touchtone phone The VRU is a fully automated tool that provides quick and easy information to providers seeking benefits and eligibility routine claim status and refund statuses We recently updated our system and if the requested information is available in the VRU you will no longer receive the option to speak to a provider services representative For BlueCross
112. sesesess 12 Important Facts About the ID Card Pret 12 Section 5 Benefit Information wisi cisssccccccivcsesessenscsescecscsuscccansascncanesecneasiecctansenectaauseectaazeasasseacaaasecdodaasecduaadsescaaases 13 Benefit e TEE 13 Preferred EE 13 Preferred Blue Mental Health Benefits ccccccccccceeeeeee cece cere ener eee e eee n nnn EEE Eee EEE EEE REESE EEE EEE EEE SEES EEE E SERRE EEE EEEEEEE EES 14 Preferred Blue Prescription Drug Plans iseennast Eege 14 Preferred Blue Precertification Requirement ccccceceeeeeeeeecceeeeeeeeeeteeeaaaeeeeeeeeeeeenaaaaeeeeeeeeteeeaaaaaaaeeeeeees 14 Preferred Blue ClAINSivsscistsscdeteteesiviedbiedstedussdadedeesdsdedvecdeiri eeedebbi eecdeieieasdetedessscdasadaandaandadhduenduabdaandanhdnenansnanenane 15 Federal Employee Program FER 16 Other FEP MOn 0 eee eee eee eee rere 16 FEP Prior AuthoriZation ccccceeeee cece eee nner nnn EEE EE EEE EEE EE EEE EEE EEE EEE EERE EERE EERE EERE EERE EERE EE EERE EEE EERE EE EEE 17 NG ge Elan cas Foss eos E heed tee E A N IE OEE EENE EE 17 State Health Plan SHP s cseisccheesecithesenectites efit irinin ieii raie rria rna naanin EEEE OTR eG oda 19 Oher SHM Oma Oee ekek eienenn ERER REERSRRERRARE 19 eben le Le EE 20 Medical University of South Carolina MUSC State Health Plan 22 DIP EE eessen eee cacetens coc easediscasscedeaccetesscadecedencesdedenesoessis sed ade AN A A O E E 23 Third Party Administrators TPAs eect e eter tener tr
113. ss prohibits balance billing by network and deemed providers who provide covered services to Medicare Advantage members You should collect copayments or coinsurance for covered services from the member at the time of service If a provider either deemed or not deemed incorrectly collects more from a member than the designated copayment or coinsurance amount the provider must refund the difference to the member Advanced Beneficiary Notice ABN You should issue an Advanced Beneficiary Notice of Noncoverage to Medicare members when you expect that Medicare will deny the payment Do not use it for supplemental items or services provided under the Medicare Advantage program as outlined by Medicare BlueCross will accept a valid ABN or written agreement on provider letterhead that confirms the agreement between you and the member You should notify the member at the time of service if Medicare statutorily excludes that service and have the member complete a valid ABN or written agreement on provider letterhead Collect payment up front from the member for statutorily excluded services or items and then electronically file the claim with a GY modifier to the Medicare Advantage plan BlueCross will conduct post adjudication review to ensure you used the GY modifier appropriately and it s supported by a valid executed ABN or written agreement on provider letterhead If an ABN or written agreement is deemed invalid and not acceptable the member is not l
114. t categories with the addition of a fourth or fifth digit to provide specificity or additional information regarding etiology site or manifestations It is necessary to use the current edition of the codebook when filing claims The applicable codebooks include but are not limited to ICD 9 CM Volumes 1 2 and 3 CPT and the Healthcare Common Procedure Coding System HCPCS Modifiers A modifier lets the reporting provider indicate that a specific circumstance has altered a service or procedure but not changed its definition or code You should use modifiers appropriately Visit www CMS gov for the most up to date information on valid and invalid modifiers Filing Claims As a participating network provider you agree to submit claims for BlueCross FEP BlueCard out of area and State Health Plan members electronically using the HIPAA compliant 837 I or P X12 format You should complete all applicable claim information in full to ensure you receive accurate payment without delay BlueCross Supplemental Implementation Guides SIGs are available in the HIPAA Critical Center at www HIPAACriticalCenter com These will help you with the electronic claim filing process You can also file both professional and institutional claims primary secondary and corrected claims by using My Insurance Manager BlueCross BlueShield of South Carolina is an independent Page 55 licensee of the Blue Cross and Blue Shield Association South Carolina S
115. t of claim e Error identification for immediate correction For assistance or information about submitting electronic claims please contact the EDI Help Desk at 800 868 2505 We require all professional providers to submit electronic claims in the HIPAA X12 format You can also view a list of vendors who are currently submitting HIPAA compliant claims to us as certified vendors Carrier Codes BlueCross uses carrier codes payer codes to route electronic transactions to the appropriate line of business once the Gateway accepts the claim Failure to use the correct electronic carrier code will result in misrouted claims or delayed payments Here are the carrier codes 400 State Health Plan SHP 401 BlueCross BlueShield of South Carolina including all out of state BlueCard claims 402 Federal Employee Program FEP 922 BlueChoice HealthPlan 886 Planned Administrators Incorporated PAI 315 Thomas Cooper amp Company 446 Key Benefit Administrators KBA C63 Medicare Advantage Preferred Provider Organization PPO Planned Administrators Inc and Thomas Cooper amp Company are separate companies that offer third party administration services on behalf of BlueCross Key Benefit Administrators is an independent company that offers third party administration services on behalf of BlueCross BlueCross BlueShield of South Carolina is an independent Page 80 licensee of the Blue Cross and Blue Shield Association
116. t whose birth month regardless of birth year falls later in the year e Dependent children of divorced or separated parents If there is a court decree establishing financial responsibility for a child s health care the plan of the parent assigned that responsibility is primary If the parents have joint custody either the Birthday or Gender Rule will apply depending on which rule governs the contracts Gender Rule The father s insurance plan is primary for dependent children Birthday Rule The plan of the parent born earlier in the year is primary for dependent children For example if the father s birth date is March 1 1950 and the mother s birth date is February 1 1952 the mother s plan will be primary for the children because her birthday occurs earlier in the year than the father s Each state decides whether to use the Gender or the Birthday Rule In South Carolina the Birthday Rule is used for fully insured group plans with effective or anniversary dates on or after June 1 1990 If BlueCross must coordinate with an insurance plan that uses the Gender Rule and this results in a conflict the Gender Rule will be followed BlueCross BlueShield of South Carolina is an independent Page 50 licensee of the Blue Cross and Blue Shield Association South Carolina Other Factors Under COB Regulations Preservation of the Primary Plan s Cost Containment Features The secondary plan can exclude from consideration any b
117. tandard option members can use both preferred and non preferred providers FEP ID numbers begin with the letter R and the card reads BlueCross BlueShield Federal Employee Program Sample FEP ID Cards y BlueCross Govemment Wide Kid BlueCross Goverment Wide z s A BlueShield Service Benefit Plan D S d BlueShield Service Benetit Plan Federal Employee Program Federal Employee Program Member Name www fepblue org Member Name www fepblue org 1M Sample IM Sample Member ID Member ID R99999999 R99999999 EnrolimentCode 702 0 WIN 610239 Enrollment Code 104 San 610239 Effective Date 01 01 2008 RxPCN FEPRx Effective Date 01 01 2008 AxPCN FEPRx RxGrp 65006500 AxGrp 65006500 You can access member benefit booklets on the FEP website at www FEPBlue org Other FEP Information FEP Mental Health Benefits Precertification is not required for outpatient mental health services FEP Prescription Drug Plan FEP members have drug coverage through Caremark They have a five tier plan with either a drug card and or mail service benefits You can download the preferred drug list through the FEP website at www FEPBlue org Federal Employee Program Fee Allowances FEP uses the preferred provider network of health care providers along with the Preferred Blue PPO fee allowance schedule If you are credentialed and participating in the PPO program you are automatically an FEP network provider This means that the member is not
118. th Insurance Claim Form or Loop 2310A claim level on the 837 Professional Electronic Submission File the claim to the Plan whose state the Ordering Physician is located Patient is seen by a physician in Ohio who orders a specialty pharmacy injectable for the patient Patient will receive the injections in South Carolina where the member lives for 6 months of the year File to Blue Cross Blue Shield of Ohio BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association Page 39 South Carolina These rules apply regardless of your contracting status with the Blue Plan where you file the claim Before providing any ancillary service please verify a member s eligibility and benefits by calling the number on the back of the member s ID card Or you can call 800 676 BLUE 2583 If you use an outside vendor to provide services eg you send a blood specimen for special analysis that the lab where the specimen was drawn cannot do please use an in network ancillary provider This will reduce the possibly that the member will be liable for more costs Members are financially liable for ancillary services not covered under their benefit plans It is your responsibility to request payment directly from the member for non covered services Contiguous Counties A contiguous area is generally a border county in another Plan s service area one county over from the Pl
119. th Carolina is an independent licensee of the Blue Cross and Blue Shield Association BlueCross BlueShield of South Carolina is an independent Page 91 licensee of the Blue Cross and Blue Shield Association South Carolina Section 19 www SouthCarolinaBlues com In keeping with the latest technology BlueCross BlueShield of South Carolina provides health care information available at your fingertips at www SouthCarolinaBlues com South Carolina Home Insurance Basics Shop Member Perks Live Healthy v Because it matters how voure treated A Kl Here s Why Avoid the Penalty Enroll by March 31 We ll help you find a health insurance plan that s right for you You may be eligible for lower monthly costs If you are we ll help you apply Even if you re not eligible we have lots of easy ways to shop for coverage D ef 2014 HEALTH PLANS of Oe About Us Ne X Need Assistance Wes urac urac 4 ed e OCREDITED gt Member Login Username Password ee onge Forgot Forgot Username Forgo Password i Shop for Insurance See Our Plans South Carolina BLUE Retail Center o Get a Quote Find an Agent Individual amp Famil FA Find a Doctor or Hospital Find a Provider o Print a Directory ei Worldwide Directory o Q000 All information is real time and confidential To protect privacy and comply with HIPAA standards we use the latest encryption technology to ensure that
120. the Medical Review Form Levels of Appeals e Level 1 Redetermination Appealing the initial decision by BlueCross If you disagree with the plan s decision of how a claim was processed you can request a redetermination The time limit for filing the appeal request is 120 days from the date of receipt of the initial determination After reviewing BlueCross will decide whether the initial decision should be affirmed dismissed or reversed e Level 2 Reconsideration Request for a review by an independent review organization If the claim has gone through the first level appeal process and you are still dissatisfied you can request an independent review organization review the claim The time limit for filing the appeal request at this level is 180 days from the date of receipt of the redetermination The organization will review the request and decide to affirm dismiss or reverse the original decision e Level 3 Administrative Law Judge ALJ Hearing At this level of appeal request you can ask for an administrative law judge to consider the case and make a decision The time limit for filing the appeal request is 60 days from the date of receipt of the reconsideration The monetary threshold to be met is at least 130 that remains in controversy e Level 4 Departmental Appeals Board DAB Review At this level of appeal request the Departmental Appeals Board can review the case The time limit for filing the appeal request is 60 days f
121. the standardized information in a conventional format Instantly see patient errors and denials My Remit Manager highlights any claims that have errors or that BlueCross has denied View information categorized by check numbers or by patient My Remit Manager clearly lists the name of each patient whose EOB is associated with an individual check or EFT Print individual remits for a single patient Eliminate the need to remove or blackout other patient information on the remit Print remits for selected patients Print individual or group remits Generate and analyze reports Analyze claim payment subscriber CPT code etc specific data over a specific time period In order to access My Remit Manager please contact Provider Education at 803 264 4730 to request us to set up a profile for you You can submit your request via email to Provider Education bcbssc com BlueCross BlueShield of South Carolina is an independent Page 58 licensee of the Blue Cross and Blue Shield Association South Carolina Section 13 Medical Management Most BlueCross members have managed care requirements in their contracts These requirements make sure inpatient stays are medically necessary and the members are spending their health care dollars wisely All members have ID cards showing the preadmission review requirements and the telephone numbers for reporting admissions Precertification is also known as prior authorization preauthorization pre service r
122. to include all supporting medical documentation and fax to the appropriate fax number on the bottom of the Medical Review Form BlueCross BlueShield of South Carolina is an independent Page 23 licensee of the Blue Cross and Blue Shield Association South Carolina Third Party Administrators TPAs Several health insurance administrators use the BlueCross Preferred Blue network of health care providers Here are active third party administrators that access the network e Planned Administrators Inc PAI e Thomas H Cooper amp Company Inc TCC e Companion Property amp Casualty P amp C e Key Benefit Administrators PAI TCC and Companion P amp C are separate companies and Key Benefit Administrators is an independent company that provides third party administration services on behalf of BlueCross Precertification for services follows the rules of each plan Please review the membere ID card to determine the appropriate contact numbers for precertification File all TPA claims with the exception of Companion P amp C electronically to BlueCross using the appropriate carrier codes BlueCross will forward the claim electronically to the individual TPA File claims for Companion P amp C directly to Companion P amp C Attention Bill Review Unit Post Office Box 100165 Columbia SC 29202 3165 The TPA will apply benefits adjudicate the claim and make payment on its remittance advice Contact the individual carriers for claim stat
123. ueCross BlueShield of Arizona BlueCross BlueShield of Florida BlueCross BlueShield of Georgia BlueCross BlueShield of Kansas BlueCross BlueShield of North Carolina BlueCross BlueShield of North Dakota BlueCross BlueShield of South Carolina BlueCross BlueShield of Tennessee BlueCross BlueShield of Vermont BlueCross of Idaho Capital BlueCross Dominion Dental CareFirst BlueCross BlueShield DeCare Dental Empire BlueCross BlueShield Excellus BlueCross BlueShield Horizon Blue Cross Blue Shield of New Jersey Wellmark Wellpoint These Plans are independent licensees of the Blue Cross and Blue Shield Association BlueCross BlueShield of South Carolina is an independent Page 44 licensee of the Blue Cross and Blue Shield Association South Carolina FEP BlueDental GRID Dental Corporation GDC is a separate company that administers FEP BlueDental on behalf of BlueCross FEP BlueDental members use the GRID network as an in network provider source Participating providers now have access to FEP BlueDental members How to Identify FEP BlueDental Plan Members The ID card will indicate the provider network GRID member s identification number group number program name and on the reverse side the address to send the claims and the customer service telephone number The lower left corner of the membere ID card will display GRID indicating the use of the GRID network The ID card is for identification ONLY The ID card is not a
124. under the BlueCard program Stand alone dental and prescription drugs Stand alone vision and hearing Claims for FEP are exempt from the BlueCard program You should submit FEP claims to the administering Plan in the state where you provide services BlueCross BlueShield of South Carolina is an independent Page 33 licensee of the Blue Cross and Blue Shield Association South Carolina The BlueCard Process Illustration Local Plan applies pricing according to the provider s contract and electronically forwards the claim to the Provider submits claim to local Plan member s home Plan Home Plan processes according to membere benefits and transmits data back to local Plan Home Plan sends EOB to member Local Plan sends remittance and payment to provider BlueCross BlueShield of South Carolina is an independent Page 34 licensee of the Blue Cross and Blue Shield Association How to Identify BlueCard Members South Carolina When members from other BlueCross and or BlueShield Plans arrive at your office or facility be sure to ask for their current membership ID cards You can identify BlueCard members by the alpha prefix a blank suitcase logo or a PPO in the suitcase logo on their cards Sample ID Cards A BlueCross BlueShield D Ble ALPHA Oa or Geography Product Employer Group Member Name Dependents Member Name Dependent One er ID Dependent Two 3456789 Dependent Three Grpup
125. uperbill The Superbill tool within My Insurance Manager is ideal for professional providers who want to submit primary claims for a single date of service You can create and store your Superbill online then use it to submit a professional Web claim with minimal keystrokes It takes only seconds to submit a claim to BlueCross and you will receive instant claim disposition Timely Filing All plans have time limitations for claim submission Generally providers must file claims within 180 days from the date of service Some policies however require you to file claims within 90 days Since timely filing limits vary you are encouraged to file your claims as soon as possible BlueCross will deny claims it receives after the timely filing period The member and BlueCross should be held harmless for these amounts Note Timely filing limits are subject to change You can verify timely filing limits by checking eligibility and benefits in My Insurance Manager Provider Number Each participating provider should use his or her Tax Identification Number TIN or National Provider Identifier NPI when filing claims This will ensure accurate and timely payment An exception to this occurs if you do not have a TIN and use your Social Security Number to report income Place your provider number in the appropriate form indicator for the 837 I and P when filing claims Follow these same instructions for entering the rendering provider s NPI number
126. urance Manager BlueCross BlueShield of South Carolina is an independent Page 71 licensee of the Blue Cross and Blue Shield Association South Carolina Section 15 Medical Review Review A review is a request for reconsideration based on extenuating medical circumstances when BlueCross denies a claim or there is a discrepancy in the denial or payment amount Examples include e Cosmetic and procedures that are not medically necessary e Multiple surgery or medical care a patient receives on the same day e Extenuating medical circumstances supporting additional reimbursement Complete a Medical Review Form found on our website in the Forms section Attach the applicable medical records and supporting information to the form Fax or mail the form and supporting documents to the appropriate service area This information may include but is not limited to Records from the primary or referring physician Operative notes Office notes Discharge notes Do not submit a review for claim status or for a service that is not a covered benefit It generally takes BlueCross 30 days to complete reviews and initiate claim adjustments or generate letters of denial to providers Appeals An appeal is a second line review you can request after BlueCross has reviewed a claim and upheld its original decision Complete a Medical Review Form and indicate it is an appeal by checking the appropriate box Attach additional medical records supporting inf
127. ures is in the Coordination of Benefits COB section The SHP Medicare Supplement Plan will never pay for charges that are more than the SHP s allowed amount BlueCross BlueShield of South Carolina is an independent Page 19 licensee of the Blue Cross and Blue Shield Association South Carolina For the Medicare Supplement Plan we pay the coinsurance and deductible amounts for Medicare covered services Dependents on this plan without Medicare are covered using the Standard Plan s provisions The Medicare Supplement Plan does cover a limited number of benefits not covered by Medicare which you can identify by accessing benefit information in My Insurance Manager at www sSouthCarolinaBlues com You can also access the members benefit booklet on the State employee website at https StateSC SouthCarolinaBlues com web public statesc The State Health Plan participates in Coordination of Benefits Agreement COBA so we automatically receive cross over claims for Medicare primary members If you receive notification that a claim has crossed over you should not file separate claims directly to BlueCross SHP Mental Health Benefits CBA is the behavioral health manager that handles mental health and substance abuse treatment precertification case management and provider networks for the SHP Providers can contact CBA by calling one of these numbers Companion Benefit Alternatives 803 699 7308 P O Box 100185 800 868 1032 Columbia SC 292
128. us Place your provider number in the appropriate form indicator for the 837 I and P when filing claims Follow these same instructions for entering the rendering provider s NPI number BlueCross BlueShield of South Carolina is an independent Page 24 licensee of the Blue Cross and Blue Shield Association South Carolina Section 6 BlueCross Medicare Advantage Plans We offer two Medicare Advantage plans to Medicare eligible recipients in South Carolina These plans are Medicare Blue and Medicare Blue Saver You should confirm the level of coverage for all Medicare Advantage members before providing services because level of benefits and coverage rules may vary Medicare Advantage PPO e Medicare Blue e Medicare Blue Saver Medicare Blue Medicare Blue is a Medicare Advantage PPO product that combines the benefits of traditional Medicare with Medicare Part D prescription drug coverage Members can go to any doctors specialists or hospitals in the network A member can choose an out of network provider but he or she may have to pay more for services Sample Medicare Blue ID Card 9 South Carolina MEDICARE BUET Member Name www scbluewnedadvantage com SUBSCRIBER NAME KI H South Carolina Sa 1 888 649 6025 Member ID TTY Users 1 888 645 6023 Pharmacy Help Lire 1 800 545 6512 ZCT012345678901 Dental Vision Care Services 1 877 225 7460 TY RxBIN 016862 Members Use retwork services for maximum Paor Aaronin 1 000 327 3003 RxGRP
129. vice benefits Benefits for some Preferred Blue members however are provided under their medical plans with optional mail service benefits You can learn more about our prescription drug benefits including precertification and other utilization management requirements on the Prescription Drug Information area of our website Preferred Blue Precertification Requirements Inpatient Services Most inpatient procedures and admissions require precertification also known as prior authorization preauthorization pre service review or pre admission review but are contract specific The preferred method for submitting precertification requests for Preferred Blue members is through My Insurance Manager on our website www SouthCarolinaBlues com Outpatient Services These outpatient procedures may require precertification Septoplasty Sclerotherapy performed in an outpatient or office setting Chemotherapy radiation therapy one time notification Hysterectomy Procedures that may be cosmetic in nature You must submit these for review in writing five to seven days before the scheduled procedure Include pictures if appropriate blepharoplasty reduction mammoplasty TMJ surgery etc BlueCross has added special programs for patients undergoing chemotherapy and radiation therapy You need to notify BlueCross about any patients receiving these services BlueCross BlueShield of South Carolina is an independent Page 14 licensee of the Blue C
130. w much does it cost to establish an electronic connection with BlueCross Answer It depends on the features and functionality you want Internet There is no charge to access the features and services on www SouthCarolinaBlues com The only cost will be that of a computer and an Internet connection Validated Vendor The charge for an electronic connection through a validated vendor is usually included in the practice management software package A communication service charge may apply Contact the vendor of your choice for pricing details Clearinghouse A clearinghouse can either be its own validated vendor that only handles claim submission audit trail and remittance retrieval Or it can be incorporated as part of another validated vendor practice management software system that handles the claims system within that product File Transfer Protocol FTP Some validated vendors offer FTP as a connection option The use of a vendor product or script would cost more than programming directly from your Office It would however most likely offer user friendly functionality and support Although FTP is one of the options some of our validated vendors have programmed you can use it without a vendor product to connect directly to BlueCross Question How long does it take to get set up for electronic filing Answer It depends on which method of electronic communication you choose Internet setup is instant All other methods depend
131. y monitoring not done by the attending cardiologist is done by hospital personnel and we do not provide separate benefits Nerve Blocks BlueCross includes administration of a nerve block in the allowance for total anesthesia time It is not eligible for separate reimbursement When the nerve block is a separate procedure and is for the treatment of a non surgical condition or for non postoperative pain management providers should bill it using the appropriate surgical procedure Anesthesia Units Base Units BlueCross uses the Medicare base units for procedures Time Units Providers should report anesthesia time units in minutes BlueCross calculates the number of units for claims adjudication based on 15 minute increments rounded to the nearest tenth 1 10 For example we would calculate 49 minutes as follows 49 minutes 15 increment 3 266 units 3 266 would round to 3 3 time units We do not provide anesthesia benefits for e The administration of anesthesia for non covered services such as cosmetic surgery BlueCross BlueShield of South Carolina is an independent Page 67 licensee of the Blue Cross and Blue Shield Association South Carolina We do not provide separate benefits for these if in conjunction with other surgical or medical services Preoperative anesthesia consultation Transesophageal cardiography Emergency intubation The administration of anesthesia by the attending surgeon or surgical assistant except as
132. y necessary repairs Deluxe and Special Features BlueCross considers certain DME deluxe equipment due to its mechanical or electrical features e g electric hospital beds A deluxe item is any equipment with operating expenses including supplies that are in excess of the cost of the standard equipment meeting the medical necessity requirements of the plan The preferred DME provider will make physicians aware of the availability of more economical versions of DME and or orthotics and prosthetics that will meet the member s needs and quality standards We cover deluxe equipment only if it is both medically necessary and therapeutic in nature We will not pay for deluxe equipment a physician orders primarily for a members comfort or convenience that is not medically necessary and therapeutic When the member requests deluxe equipment and his or her physician does not document medical necessity for the deluxe features of covered DME we will base benefits on the rental or purchase allowance for standard economical equipment Due to certain conditions illnesses or injuries we may consider DME with special or customized features medically necessary All equipment of this type is subject to individual payment consideration before we approve DME suppliers should include charges for rental equipment accessories in the rental price of the equipment when billing BlueCross You should submit all DME requests for special or customized features to
133. y to BlueCross e f the beneficiary does not have this piggy back option file the claim to BlueCross and include a copy of the MSN You can file these electronically by using My Insurance Manager Indicate in the other coverage field that Medicare is primary e BlueCross pays the balance up to but not exceeding the Medicare allowable amount shown on the MSN When Medicare is primary and assignment is not accepted e Charge the member in full but within Medicare s guidelines e File the claim to Medicare e File the claim to BlueCross indicating in the other coverage field that the member has Medicare and has paid in full e After Medicare processes the claim the member can file a copy of the MSN to BlueCross for the balance The majority of Medicare supplemental claims will automatically cross over to BlueCross and you do not have to file secondary claims After Medicare processes benefits the claim and payment information are electronically transmitted to BlueCross BlueCross will then process the claim for supplemental benefits according to the subscriber contract Please allow sufficient time for us to receive and process your cross over claims before submitting a claim to BlueCross On average allow at least 30 days for the primary Medicare claim to cross over and for BlueCross to process the supplemental payment Do not submit a secondary claim to BlueCross until you have verified that the claim did not
134. y to BlueCross in the HIPAA compliant 8371 UB 04 format using revenue code 651 You must get prior authorization and re authorization for all hospice services Skilled Nursing Facility Skilled nursing providers should file claims electronically to BlueCross in the HIPAA compliant 837 UB 04 format File with the appropriate bill type and revenue code for the type of treatment as a single line item You must get prior authorization for all skilled nursing services Long Term Acute Care LTAC LTAC facilities should submit claims electronically to BlueCross in the HIPAA compliant 8371 UB 04 format using the appropriate revenue codes You must get prior authorization for all LTAC services IV Infusion Therapy Infusion therapy providers should file claims electronically to BlueCross in the HIPAA compliant 837P HCFA 1500 format using the appropriate CPT or HCPCS codes We encourage you to check a membere benefits and eligibility to determine if prior authorization is required Durable Medical Equipment DME DME is any equipment that provides therapeutic benefits to a patient in need due to certain medical conditions and or illnesses DME includes but is not limited to wheelchairs manual electric hospital beds traction equipment crutches walkers kidney machines ventilators oxygen monitors pressure mattresses prostheses etc DME is any equipment that can withstand repeated use and is primarily and customarily used to serve a

Download Pdf Manuals

Related Search

Related Contents

Samsung LA60C650L1M User Manual  MBG  Idrogo Instruction Manual  ユーザーズ・マニュアル - M  型番：DHV-540 販売価格：41,790 円（税込）  （平成23年版）（PDF：284KB）  Samsung CLASSIC A60 7.2W    

Copyright © All rights reserved. Failed to retrieve file