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Provider Manual 2019Blue Cross and Blue Shield of Vermont
and The Vermont Health Plan
Table of Contents
Provider Manual 2019Blue Cross and Blue Shield of Vermont and The Vermont Health Plan i
Section 1Getting in Touch with BCBSVT and TVHP 1
Plan Definitions 2
Office Training and Orientation 4
Provider Participation and Contracting 4
Access Standards 13
Availability of Network Practitioners 14
OpeningClosing of Primary Care Provider Patient Panels 14
PCP Initiated Member Transfer 15
Transitioning Pediatric Patients 15
Notification of Change in Provider andor Group Information 16
Utilization Management Denial Notices Reviewer Availability 18
Complaint and Grievance Process 18
Health Insurance Portability and Accountability Act (HIPAA) Responsibilities 19
Member Rights and Responsibilities 20
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices 20
Section 2Blue Cross and Blue Shield of Vermont Website 21
Section 3Mandates 25
Member Accumulators 25
Member Eligibility 26
Member Confidential Communications 26
Standard Confidential Communication 27
Confidential Communication for Sexual Assault 27
Member Identification Cards 27
Member Proof of Insurance 30
Section 4Medical Utilization Management (Care Management) 32
Section 5Quality Improvement (QI) Program 41
BCBSVTTVHP Special Health Programs 42
Provider Selection Standards 44
Section 6General Claim Information 47
When to Collect a Co‑payment 50
Member Confidential Communications 55
Claim Specific Guidelines 57
Section 7 The BlueCardtrade Program Makes Filing Claims Easy 76
How Does the BlueCard Program Work 76
Claim Filing 81
Frequently Asked Questions 86
Glossary of BlueCard Program Terms 88
BlueCard Program Quick Tips 89
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint Program 90
Section 9 The Federal Employee Program (FEP) 95
Index
1
Section 1General
Section 1557 of the Affordable Care Act prohibits discrimination in health care on the basis of race color national origin age disability and sex (including gender identity and sexual orientation) Pursuant to this and other federal and state civil rights laws BCBSVT does not discriminate exclude or treat people differently because of these characteristics These statements apply to our employees customers business partners vendors and providers
Getting in Touch with BCBSVT and TVHPA customer service team specializing in provider issues is available to you see the telephone directory link below The lines are open weekdays from 7 am until 6 pm Please have the following information available when you callbull Your National Provider Identifier(s)bull Your patientrsquos identification number including the alpha prefix
BCBSVT amp TVHP Telephone Directoryhttpwwwbcbsvtcomprovidercontact‑info
Contact Us
By Mail
PO Box 186 Montpelier VT 05601‑0186
In Person
445 Industrial Lane Montpelier VT 05602
On The Web
Our website wwwbcbsvtcom has a variety of services for providers and members See section 2 for more information
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure To comply we use the services of Proofpoint to protect our e‑mail and ensure all PHI remains confidential
When a BCBSVTTVHP employee sends you an e‑mail that contains PHI Proofpoint detects the PHI and protects the e‑mail You will receive an e‑mail notification that you have been sent a Proofpoint secure message The notification tells you who the secure message is from and includes a link to retrieve the e‑mail message The first time you use the Proofpoint message service to retrieve a message you must create a password Thereafter you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVTTVHP e‑mail
Please notemdashProofpoint secure messages are posted and available for 30 calendar days If the message is not opened during that time the message is removed and the sender notified
For more information about Proofpoint visit httpssecuremailbcbsvtcomhelpenus_encryptionhtm
2
Plan Definitions
CBA Bluereg
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT Providers contract for CBA through BCBSVT
CBA Blue members have unique prefixes A complete listing of prefixes for CBA Blue members is available on our provider website at wwwbcbsvtcom under referencesprefixes
Claims for CBA Blue members should be submitted to CBA Blue directly
Please contact CBA Blue directly with any customer service or claim processing related questions
Their contact information is available on our Contact Information for Provider listing on our provider website at wwwbcbsvtcom under contact us
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive Comprehensive coverage has an annual deductible amount and coinsurance up to an annual ldquoout‑of‑pocketrdquo limit It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers necessary services provided by inpatientoutpatient facilities and home health agencies ambulance services durable medical equipment medical supplies mental healthsubstance abuse services prescription drugs physical therapy and private duty nursing The provider network for Comprehensive coverage is the participating provider network
Vermont Freedom Planreg (VFP) the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers Patients may seek services from non‑participating providers but in most cases they will pay higher deductible andor coinsurance amounts The Vermont Freedom Plan provides coverage with no deductible for office visits well‑baby care and physicals This plan requires members to pay a deductible andor co‑payment The provider network for the Vermont Freedom Plan is our preferred provider network (PPO)
All plans have a prior approval requirement for select medical procedures durable medical equipment and select prescription drugs
Vermont Blue 65SM Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp) is a supplement available to individuals who have Medicare Parts A and B coverage Effective 112005 BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I II III A and C to Vermont Blue 65 Plans I II III A and C It helps pay co‑payments and coinsurance for Medicare‑approved services In some cases the individuals will have to pay for all or part of the health care services Benefits are provided only for approved Medicare‑eligible services provided on or after the effective date of coverage
BlueCardreg
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard Section 7 for details
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑based managed care organization offering a cost‑effective high‑quality portfolio of managed care products The Vermont Health Plan offers an HMO product BlueCare and a point‑of‑service plan BlueCare Options
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
Table of Contents
Provider Manual 2019Blue Cross and Blue Shield of Vermont and The Vermont Health Plan i
Section 1Getting in Touch with BCBSVT and TVHP 1
Plan Definitions 2
Office Training and Orientation 4
Provider Participation and Contracting 4
Access Standards 13
Availability of Network Practitioners 14
OpeningClosing of Primary Care Provider Patient Panels 14
PCP Initiated Member Transfer 15
Transitioning Pediatric Patients 15
Notification of Change in Provider andor Group Information 16
Utilization Management Denial Notices Reviewer Availability 18
Complaint and Grievance Process 18
Health Insurance Portability and Accountability Act (HIPAA) Responsibilities 19
Member Rights and Responsibilities 20
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices 20
Section 2Blue Cross and Blue Shield of Vermont Website 21
Section 3Mandates 25
Member Accumulators 25
Member Eligibility 26
Member Confidential Communications 26
Standard Confidential Communication 27
Confidential Communication for Sexual Assault 27
Member Identification Cards 27
Member Proof of Insurance 30
Section 4Medical Utilization Management (Care Management) 32
Section 5Quality Improvement (QI) Program 41
BCBSVTTVHP Special Health Programs 42
Provider Selection Standards 44
Section 6General Claim Information 47
When to Collect a Co‑payment 50
Member Confidential Communications 55
Claim Specific Guidelines 57
Section 7 The BlueCardtrade Program Makes Filing Claims Easy 76
How Does the BlueCard Program Work 76
Claim Filing 81
Frequently Asked Questions 86
Glossary of BlueCard Program Terms 88
BlueCard Program Quick Tips 89
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint Program 90
Section 9 The Federal Employee Program (FEP) 95
Index
1
Section 1General
Section 1557 of the Affordable Care Act prohibits discrimination in health care on the basis of race color national origin age disability and sex (including gender identity and sexual orientation) Pursuant to this and other federal and state civil rights laws BCBSVT does not discriminate exclude or treat people differently because of these characteristics These statements apply to our employees customers business partners vendors and providers
Getting in Touch with BCBSVT and TVHPA customer service team specializing in provider issues is available to you see the telephone directory link below The lines are open weekdays from 7 am until 6 pm Please have the following information available when you callbull Your National Provider Identifier(s)bull Your patientrsquos identification number including the alpha prefix
BCBSVT amp TVHP Telephone Directoryhttpwwwbcbsvtcomprovidercontact‑info
Contact Us
By Mail
PO Box 186 Montpelier VT 05601‑0186
In Person
445 Industrial Lane Montpelier VT 05602
On The Web
Our website wwwbcbsvtcom has a variety of services for providers and members See section 2 for more information
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure To comply we use the services of Proofpoint to protect our e‑mail and ensure all PHI remains confidential
When a BCBSVTTVHP employee sends you an e‑mail that contains PHI Proofpoint detects the PHI and protects the e‑mail You will receive an e‑mail notification that you have been sent a Proofpoint secure message The notification tells you who the secure message is from and includes a link to retrieve the e‑mail message The first time you use the Proofpoint message service to retrieve a message you must create a password Thereafter you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVTTVHP e‑mail
Please notemdashProofpoint secure messages are posted and available for 30 calendar days If the message is not opened during that time the message is removed and the sender notified
For more information about Proofpoint visit httpssecuremailbcbsvtcomhelpenus_encryptionhtm
2
Plan Definitions
CBA Bluereg
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT Providers contract for CBA through BCBSVT
CBA Blue members have unique prefixes A complete listing of prefixes for CBA Blue members is available on our provider website at wwwbcbsvtcom under referencesprefixes
Claims for CBA Blue members should be submitted to CBA Blue directly
Please contact CBA Blue directly with any customer service or claim processing related questions
Their contact information is available on our Contact Information for Provider listing on our provider website at wwwbcbsvtcom under contact us
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive Comprehensive coverage has an annual deductible amount and coinsurance up to an annual ldquoout‑of‑pocketrdquo limit It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers necessary services provided by inpatientoutpatient facilities and home health agencies ambulance services durable medical equipment medical supplies mental healthsubstance abuse services prescription drugs physical therapy and private duty nursing The provider network for Comprehensive coverage is the participating provider network
Vermont Freedom Planreg (VFP) the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers Patients may seek services from non‑participating providers but in most cases they will pay higher deductible andor coinsurance amounts The Vermont Freedom Plan provides coverage with no deductible for office visits well‑baby care and physicals This plan requires members to pay a deductible andor co‑payment The provider network for the Vermont Freedom Plan is our preferred provider network (PPO)
All plans have a prior approval requirement for select medical procedures durable medical equipment and select prescription drugs
Vermont Blue 65SM Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp) is a supplement available to individuals who have Medicare Parts A and B coverage Effective 112005 BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I II III A and C to Vermont Blue 65 Plans I II III A and C It helps pay co‑payments and coinsurance for Medicare‑approved services In some cases the individuals will have to pay for all or part of the health care services Benefits are provided only for approved Medicare‑eligible services provided on or after the effective date of coverage
BlueCardreg
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard Section 7 for details
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑based managed care organization offering a cost‑effective high‑quality portfolio of managed care products The Vermont Health Plan offers an HMO product BlueCare and a point‑of‑service plan BlueCare Options
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
Claim Filing 81
Frequently Asked Questions 86
Glossary of BlueCard Program Terms 88
BlueCard Program Quick Tips 89
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint Program 90
Section 9 The Federal Employee Program (FEP) 95
Index
1
Section 1General
Section 1557 of the Affordable Care Act prohibits discrimination in health care on the basis of race color national origin age disability and sex (including gender identity and sexual orientation) Pursuant to this and other federal and state civil rights laws BCBSVT does not discriminate exclude or treat people differently because of these characteristics These statements apply to our employees customers business partners vendors and providers
Getting in Touch with BCBSVT and TVHPA customer service team specializing in provider issues is available to you see the telephone directory link below The lines are open weekdays from 7 am until 6 pm Please have the following information available when you callbull Your National Provider Identifier(s)bull Your patientrsquos identification number including the alpha prefix
BCBSVT amp TVHP Telephone Directoryhttpwwwbcbsvtcomprovidercontact‑info
Contact Us
By Mail
PO Box 186 Montpelier VT 05601‑0186
In Person
445 Industrial Lane Montpelier VT 05602
On The Web
Our website wwwbcbsvtcom has a variety of services for providers and members See section 2 for more information
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure To comply we use the services of Proofpoint to protect our e‑mail and ensure all PHI remains confidential
When a BCBSVTTVHP employee sends you an e‑mail that contains PHI Proofpoint detects the PHI and protects the e‑mail You will receive an e‑mail notification that you have been sent a Proofpoint secure message The notification tells you who the secure message is from and includes a link to retrieve the e‑mail message The first time you use the Proofpoint message service to retrieve a message you must create a password Thereafter you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVTTVHP e‑mail
Please notemdashProofpoint secure messages are posted and available for 30 calendar days If the message is not opened during that time the message is removed and the sender notified
For more information about Proofpoint visit httpssecuremailbcbsvtcomhelpenus_encryptionhtm
2
Plan Definitions
CBA Bluereg
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT Providers contract for CBA through BCBSVT
CBA Blue members have unique prefixes A complete listing of prefixes for CBA Blue members is available on our provider website at wwwbcbsvtcom under referencesprefixes
Claims for CBA Blue members should be submitted to CBA Blue directly
Please contact CBA Blue directly with any customer service or claim processing related questions
Their contact information is available on our Contact Information for Provider listing on our provider website at wwwbcbsvtcom under contact us
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive Comprehensive coverage has an annual deductible amount and coinsurance up to an annual ldquoout‑of‑pocketrdquo limit It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers necessary services provided by inpatientoutpatient facilities and home health agencies ambulance services durable medical equipment medical supplies mental healthsubstance abuse services prescription drugs physical therapy and private duty nursing The provider network for Comprehensive coverage is the participating provider network
Vermont Freedom Planreg (VFP) the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers Patients may seek services from non‑participating providers but in most cases they will pay higher deductible andor coinsurance amounts The Vermont Freedom Plan provides coverage with no deductible for office visits well‑baby care and physicals This plan requires members to pay a deductible andor co‑payment The provider network for the Vermont Freedom Plan is our preferred provider network (PPO)
All plans have a prior approval requirement for select medical procedures durable medical equipment and select prescription drugs
Vermont Blue 65SM Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp) is a supplement available to individuals who have Medicare Parts A and B coverage Effective 112005 BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I II III A and C to Vermont Blue 65 Plans I II III A and C It helps pay co‑payments and coinsurance for Medicare‑approved services In some cases the individuals will have to pay for all or part of the health care services Benefits are provided only for approved Medicare‑eligible services provided on or after the effective date of coverage
BlueCardreg
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard Section 7 for details
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑based managed care organization offering a cost‑effective high‑quality portfolio of managed care products The Vermont Health Plan offers an HMO product BlueCare and a point‑of‑service plan BlueCare Options
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
1
Section 1General
Section 1557 of the Affordable Care Act prohibits discrimination in health care on the basis of race color national origin age disability and sex (including gender identity and sexual orientation) Pursuant to this and other federal and state civil rights laws BCBSVT does not discriminate exclude or treat people differently because of these characteristics These statements apply to our employees customers business partners vendors and providers
Getting in Touch with BCBSVT and TVHPA customer service team specializing in provider issues is available to you see the telephone directory link below The lines are open weekdays from 7 am until 6 pm Please have the following information available when you callbull Your National Provider Identifier(s)bull Your patientrsquos identification number including the alpha prefix
BCBSVT amp TVHP Telephone Directoryhttpwwwbcbsvtcomprovidercontact‑info
Contact Us
By Mail
PO Box 186 Montpelier VT 05601‑0186
In Person
445 Industrial Lane Montpelier VT 05602
On The Web
Our website wwwbcbsvtcom has a variety of services for providers and members See section 2 for more information
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that contain Protected Health Information (PHI) to be secure To comply we use the services of Proofpoint to protect our e‑mail and ensure all PHI remains confidential
When a BCBSVTTVHP employee sends you an e‑mail that contains PHI Proofpoint detects the PHI and protects the e‑mail You will receive an e‑mail notification that you have been sent a Proofpoint secure message The notification tells you who the secure message is from and includes a link to retrieve the e‑mail message The first time you use the Proofpoint message service to retrieve a message you must create a password Thereafter you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVTTVHP e‑mail
Please notemdashProofpoint secure messages are posted and available for 30 calendar days If the message is not opened during that time the message is removed and the sender notified
For more information about Proofpoint visit httpssecuremailbcbsvtcomhelpenus_encryptionhtm
2
Plan Definitions
CBA Bluereg
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT Providers contract for CBA through BCBSVT
CBA Blue members have unique prefixes A complete listing of prefixes for CBA Blue members is available on our provider website at wwwbcbsvtcom under referencesprefixes
Claims for CBA Blue members should be submitted to CBA Blue directly
Please contact CBA Blue directly with any customer service or claim processing related questions
Their contact information is available on our Contact Information for Provider listing on our provider website at wwwbcbsvtcom under contact us
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive Comprehensive coverage has an annual deductible amount and coinsurance up to an annual ldquoout‑of‑pocketrdquo limit It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers necessary services provided by inpatientoutpatient facilities and home health agencies ambulance services durable medical equipment medical supplies mental healthsubstance abuse services prescription drugs physical therapy and private duty nursing The provider network for Comprehensive coverage is the participating provider network
Vermont Freedom Planreg (VFP) the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers Patients may seek services from non‑participating providers but in most cases they will pay higher deductible andor coinsurance amounts The Vermont Freedom Plan provides coverage with no deductible for office visits well‑baby care and physicals This plan requires members to pay a deductible andor co‑payment The provider network for the Vermont Freedom Plan is our preferred provider network (PPO)
All plans have a prior approval requirement for select medical procedures durable medical equipment and select prescription drugs
Vermont Blue 65SM Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp) is a supplement available to individuals who have Medicare Parts A and B coverage Effective 112005 BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I II III A and C to Vermont Blue 65 Plans I II III A and C It helps pay co‑payments and coinsurance for Medicare‑approved services In some cases the individuals will have to pay for all or part of the health care services Benefits are provided only for approved Medicare‑eligible services provided on or after the effective date of coverage
BlueCardreg
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard Section 7 for details
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑based managed care organization offering a cost‑effective high‑quality portfolio of managed care products The Vermont Health Plan offers an HMO product BlueCare and a point‑of‑service plan BlueCare Options
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
2
Plan Definitions
CBA Bluereg
CBA Blue is a third‑party administrator (TPA) owned by BCBSVT Providers contract for CBA through BCBSVT
CBA Blue members have unique prefixes A complete listing of prefixes for CBA Blue members is available on our provider website at wwwbcbsvtcom under referencesprefixes
Claims for CBA Blue members should be submitted to CBA Blue directly
Please contact CBA Blue directly with any customer service or claim processing related questions
Their contact information is available on our Contact Information for Provider listing on our provider website at wwwbcbsvtcom under contact us
Federal Employee Program (FEP)
The Federal Employee Program (FEP) is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Indemnity (Fee-for-Service) and Preferred Provider Organization (PPO)
Comprehensive Comprehensive coverage has an annual deductible amount and coinsurance up to an annual ldquoout‑of‑pocketrdquo limit It provides benefits for medical and surgical services performed by licensed physicians and other eligible providers necessary services provided by inpatientoutpatient facilities and home health agencies ambulance services durable medical equipment medical supplies mental healthsubstance abuse services prescription drugs physical therapy and private duty nursing The provider network for Comprehensive coverage is the participating provider network
Vermont Freedom Planreg (VFP) the Vermont Freedom Plan combines the features of our Comprehensive coverage with a managed benefit program The plan encourages patient responsibility and involvement in health care by encouraging members to choose participating providers Patients may seek services from non‑participating providers but in most cases they will pay higher deductible andor coinsurance amounts The Vermont Freedom Plan provides coverage with no deductible for office visits well‑baby care and physicals This plan requires members to pay a deductible andor co‑payment The provider network for the Vermont Freedom Plan is our preferred provider network (PPO)
All plans have a prior approval requirement for select medical procedures durable medical equipment and select prescription drugs
Vermont Blue 65SM Medicare Supplemental Insurance (formerly Medi-Comp)
Vermont Blue 65 (formerly Medi-Comp) is a supplement available to individuals who have Medicare Parts A and B coverage Effective 112005 BCBSVT changed the name of its Medicare Supplemental plans from Medi‑Comp I II III A and C to Vermont Blue 65 Plans I II III A and C It helps pay co‑payments and coinsurance for Medicare‑approved services In some cases the individuals will have to pay for all or part of the health care services Benefits are provided only for approved Medicare‑eligible services provided on or after the effective date of coverage
BlueCardreg
See BlueCard Section 7 for details
New England Health Plan (NEHP)
See BlueCard Section 7 for details
The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermont‑based managed care organization offering a cost‑effective high‑quality portfolio of managed care products The Vermont Health Plan offers an HMO product BlueCare and a point‑of‑service plan BlueCare Options
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
3
TVHP plans encourage members to stay healthy by providing preventive care coverage at no cost to the member Members must get prior approval for certain medical procedures durable medical equipment and certain prescription drugs They must also get prior approval for out‑of‑network services
Members must use network providers for mental health and substance abuse care These services also require prior approval
BlueCare Access Members use the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive the preferred level of benefits
BlueCarereg A PCP within The Vermont Health Planrsquos network coordinates a memberrsquos health care Members must get prior approval for certain services and prescription drugs No out‑of‑network benefits are available without prior approval
BlueCare Options A network PCP coordinates a memberrsquos health care but members have the option of seeking care out of network at a lower benefit level (standard benefits) Standard benefits apply when members fail to get the Planrsquos approval to use non‑network providers (subject to the terms and conditions of the subscriberrsquos contract) Members pay higher deductibles and coinsurance with standard benefits If members receive care within the network or get appropriate prior approval they receive a higher level of benefits (preferred benefits)
Members with TVHP benefits can be identified by alpha prefix ZIE
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network PCP Members pay a co‑payment for services provided by their PCPs (except defined preventive care)as well as specialty office visits VHP covers hospital care emergency care home health care mental health and substance abuse treatment Co‑payments or deductibles may apply
Members must get prior approval for out‑of‑network care certain medical procedures durable medical equipment and certain prescription drugs
VHP offers two levels of benefits preferred and standard Members get preferred benefits when using VHP network providers or when they get our prior approval to use out‑of‑network providers Standard benefits are available for some out‑of‑network services meaning higher out‑of‑pocket expenses for the member
Members must use network mental health and substance abuse care providers and must get prior approval
Members with VHP benefits can be identified by the alpha prefix ZIH
University of Vermont Open Access PlanSM
University of Vermont Open Access Plan This open access plan is based on our Vermont Health Partnership product It differs in that it allows members to utilize the BlueCard Preferred Provider Organization (PPO) network when receiving services outside of the State of Vermont and still receive a preferred level of benefits Please refer to Vermont Health Partnership definition for full details
Riders
Riders amend subscriber contracts They usually add coverage for services not included in the core benefits Employer groups may purchase one or more riders Examples include
bull Prescription Drugsbull Vision Examinationbull Vision Materialsbull Fourth Quarter carry‑over of deductiblebull Benefit Exclusion Rider
bull Infertility Treatmentbull Sterilizationbull Non‑covered Surgerybull Dental Care
4
Office Training and OrientationYour BCBSVT provider relations consultant can assist you in several ways
bull Provider contracting information and interpretationbull On‑site visitsbull Provider and office staff education and trainingbull Information regarding BCBSVT policies procedures programs and servicesbull Information regarding electronic claims options
Provider Participation and ContractingProviders contract with BCBSVT andor TVHP either directly or through Physician Hospital Organizations (PHOs) If you contract with BCBSVT andor TVHP through a PHO or physicianhospital group you may obtain a copy of your contract with us from the PHO administrative offices with which you are affiliated If you contract directly with BCBSV TTVHP you are given a copy of the contract signed by all parties at the time of its execution
Contracting
Provider contracts define the obligations of all parties Responsibilities include but are not limited to obligations relating to licensure professional liability insurance the delivery of medically necessary health care services levels of care rights to appeal maintenance of written health records compensation confidentiality the term of the contract the procedure for renewal and termination and other contract issues All parties affiliated are responsible for the terms and conditions set forth in that contract Refer to your contract(s) to verify the BCBSVT andor TVHP products with which you participate You may have separate contracts or amendments for participation in different BCBSVT andor TVHP products such as Indemnity (fee‑for‑service) Federal Employee Program Vermont Health Partnership or The Vermont Health Plan
Note The BCBSVT Quality Improvement policy Provider Contract Termination policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Participation
The following provider contracts are available
Indemnity (fee-for-service)Vermont Health Partnership
A combined contract that includes participation inbull Accountable Bluebull BlueCard (out‑of‑area) Programbull CBA Bluebull Federal Employee Program (excluding dental services)bull Medicare Supplemental Insurance (Vermont Blue 65 formerly Medi‑comp)bull Preferred Provider Organization (PPO) (Vermont Freedom Plan)bull Traditional Indemnity (Fee‑for‑Service) Plans (J Plan Comprehensive and Vermont Freedom Plan)bull University of Vermont Open Accessbull Vermont Health Partnershipbull Any other program bearing the BCBS service marks
The Vermont Health Plan Contractbull Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP are participating providers or in‑network providers These providers submit claims directly to us and receive claim payments from us Participating and network providers accept the Plans
5
allowed price as payment in full for covered services and agree not to balance bill Plan members TVHP members pay any co‑payments deductibles and coinsurance amounts up to the allowed price as well as any non‑covered services
Incentives for Participation
Participation with the Plan offers the following advantagesbull Direct payment for all covered services offers predictable cash flow and minimizes collection activities and bad debt exposurebull Claims you submit are processed in a timely manner We make available either electronic (PDF or 835 formats) or paper remittance advices which detail
our payments patient responsibilities adjustments andor denialsbull Electronic Paymentsbull Members receiving services are provided with a Summary of Health Plan statement identifying payments deductible coinsurance and co‑payment
obligations adjustments and denials The memberrsquos Summary of Health Plan explains the providerrsquos commitment to patients through participation with BCBSVT andor TVHP
bull The Plan has dedicated professionals to assist and educate providers and their staff with the claims submission process policy directives verification of the patientrsquos coverage and clarification of the subscriberrsquos and providerrsquos contract
bull Online and paper provider directories contain the name gender specialty hospital andor medical group affiliations board certification if the provider is accepting new patients languages spoken by the provider and office locations of every eligible provider These directories are available at no charge to current and potential members and employer groups This information is also available to provider offices for references or referrals on our website at wwwbcbsvtcom For more information on provider directories refer to Providers Listing in Member Directories later in this section
bull Providers and their staff are given information on policies procedures and programs through informational mailings newsletters workshops and on‑site visits by provider relations consultants
bull The Plan accepts electronically submitted claims in a HIPAA‑compliant format and provides advisory services for system eligibility Automatic posting data is available to electronic submitters
bull Participating providers have around‑the‑clock access to the BCBSVT website at wwwbcbsvtcom which provides claims status information member eligibility medical policies and copies of informative mailings
Definition of Network Provider
BCBSVTTVHP defines Primary Care Provider and Specialty Care Provider by the following
Primary Care Provider (PCP)
The BCBSVT Quality Improvement Policy PCP Selection Criteria Policy provides the complete details of the selection criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
A network provider with members in managed care health plans may select to manage their care Providers are eligible to be PCPs if they have a specialty in family practice internal medicine general practice pediatrics geriatrics or naturopathy
Certain Advance Practice Registered Nurses (APRN) can carry a patient panel Specifically the APRN must practice in a state that permits APRNs to carry a patient panel and otherwise meet BCBSVT requirements for primary care providers as defined by the Quality Improvement Policy In addition the APRN must have completed transition to practice requirements and must hold certification as an adult nurse provider family nurse practitioner gerontological nurse practitioner or pediatric nurse practitioner
APRNs cannot be primary care providers for New England Health Plan Members
Specialty Care Provider (SPC) A network provider who is not considered a primary care provider
6
Enrollment of Providers
To enroll the group or individual must hold a contract with BCBSVT andor TVHP or a designated entity and the individual providers to be associated must be enrolled and credentialed
EnrollmentmdashThe forms for enrolling are located on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing There are two forms The Provider Enrollment Change Form (PECF) and the Group Provider Enrollment Change Form (GPECF) Form(s) must be completed in their entirety and include applicable attachments as defined on the second page of each form If you are a mental health or substance abuse clinician in addition to the forms mentioned above you also need to complete and Area of Expertise Form
The PECF must be used for adding a new physicianprovider to a practice (new or existing) opening or closing of patient panel changing physicianproviders practicing location termination of a physicianprovider from group and changing of a physicianproviders name
Please note We will accept an email for termination of a provider rather than the PECF Please see details below in DeletingTerminating a Provider section
The GPECF must be used for enrolling a new group practice including independent providers in a private practice setting or updating an existing groups information such as tax identification number group billing national provider identifier (NPI) billing physical or correspondence addresses andor group name Note new groupspractices need to complete the GPECF and a PECF for each physicianprovider that will be associated with that grouppractice
Mental Health and Substance Abuse clinicians must complete an Area of Expertise form in addition to the forms listed above
Independent physiciansproviders need to complete both the PECF and GPECF for enrollment or changes
Blueprint Patient Centered Medical Homes (existing or new) need to inform BCBSVT of provider changes (defined above) by using the PECF or of group practice changes (defined above) by using the GPECF The Blueprint Payment Roster Template is not our source of record for these changes
PLEASE NOTE BCBSVT is able to accept enrollment paperwork and begin the enrollment and credentialing process even if a provider is pending issuance of a State of Vermont Practitionerrsquos license If this is the case simply indicate on the Provider Enrollment Change Form ldquopendingrdquo for license number in Section 3 Provider Information Upon your receipt of the license immediately forward a copy by fax (802) 371‑3489) or e‑mail (providerfilesbcbsvtcom) or if you prefer mail a copy to Network Management at BCBSVT PO Box 186 Montpelier VT 05601‑0186 Upon receipt of the Vermont State licensure BCBSVT will continue the enrollment process Please be aware the enrollment process cannot be fully completed until all paperwork is received
Enrollment of Locum TenensmdashYou must complete a Provider EnrollmentChange form and indicate in Section 3 Locum Tenens who the provider is covering for and how long they will be covering Locum Tenens who will be covering for another provider for a period of 6 months or less do not require credentialing If the coverage is expected to exceed 6 months credentialing paperwork must be filed Locum Tenens are not marketed in directories and if in a primary care practice setting cannot hold a direct patient panel
Enrollment of Trainees for Mental HealthSubstance Abuse defined as
bull Masters Level Trainee
bull Psychiatric Clinical Nurse Specialist Trainee
bull Psychiatric Mental Health Nurse Practitioner Trainee
bull Psychiatrist Trainee
bull Psychologist Trainee
Enrollment with BCBSVT is not required however BCBSVT requires that the trainee has applied for and been granted entry on the Vermont Roster of Non‑Licensed Non‑Certified (NLNC) Psychotherapists or equivalent if in another jurisdiction consistent with 26 VSA sect 3265
See Section 6 for claim specific billing requirements
Provider CredentialingmdashThe first step is to complete or update a Council for Affordable Quality Healthcare (CAQH) application We are providing high level details below however for complete detailed instructions please refer to the Provider Quick Reference Guide on the CAQH website
Providers should use httpsproviewcaqhorgpr to access their CAQH application
7
Practice managers should use httpsproviewcaqhorgpm to access the providers CAQH application
If you encounter any issue using the CAQH website or have questions on the process please contact the CAQH Provider Help Desk at (888) 599‑1771
1 Providers Currently Affiliated with CAQHbull Log onto httpsproviewcaqhorgpr using your CAQH ID numberbull Re‑attest the information submitted is true and accurate to the best of your knowledge Please note that malpractice insurance information must be up
to date and attached electronically Also practice locations need to be updated to indicate the group that the provider is being enrolled inbull If you do not have a ldquoglobal authorizationrdquo you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
2 Providers Not Yet Affiliated with CAQHbull CAQH has a self‑registration process Go to httpsproviewcaqhorgpr if you are the provider you are a practice manager use
httpsproviewcaqhorgpm to complete an initital registration form The form will require the providerpractice to enter identifying information including an email address and NPI number
bull Once the initial registration form is completed and submitted the providerpractice manager will immediately receive an email with a new CAQH provider ID
bull Login to CAQH with the ID and create a unique username and passwordbull Complete the online credentialing application be sure to include copies of current medical license malpractice insurance and if applicable Drug
Enforcement Agency Licensebull If you do not have a global authorization you will need to assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing
information
bull If a participating organization you wish to authorize does not appear please contact that organization and ask to be added to their provider roster
Providers Without Internet Accessbull Providers without Internet access must contact CAQHrsquos Universal Credentialing DataSource Help Desk at (888) 599‑1771 and request a CAQH application
be mailed to youbull You must complete the application and return to CAQH for entry at
ACS Health Care Solutions Attn (CAQH) 4550 Victory Lane Indianapolis IN 46203 or FAX (866) 293‑0414
bull Please include copies of current medical license malpractice insurance coverage and DEA certificate (if applicable)bull Assign BCBSVT as an authorized agent allowing BCBSVT access to your credentialing information
Once authorization has been given and your application is complete CAQH will provide notification and Med Advantage will begin to process your application and primary source verify your credentialing information
If for some reason your primary source verification exceeds 60 days you will be notified in writing of the status and every 30 days thereafter until the credentialing process is complete
Upon completion of credentialing you or your group practice will receive a confirmation of your assigned NPI networks in which yoursquore enrolled and your effective date
Med Advantage
If you apply for credentialing through the BCBSVTTVHP joint credentialing committee primary source verification will be completed by our agent the National Credentialing Verification Organization (NCVO) of Med Advantage
8
Provider Listing in Member Directories
All providers are marketed in the on line and paper provider directories except those noted belowbull Providers who practice exclusively within the facility or free standing settings and who provide care for BCBSVT members only as a result of members
being directed to a hospital or a facilitybull Dentist who provide primary dental care only under a dental plan or riderbull Covering providers (eg locum tenens)bull Providers who do not provide care for members in a treatment setting (eg board‑certified consultants)bull The following provider information is supplied in the directoriesbull Name including both first and last name of the physician or providerbull Genderbull Specialty determined based on education and training and when applicable certifications held during the credentialing process Providers may
request to be listed in multiple specialties if their education and training demonstrates competence in each area of practice Approved lists of specialties and certificate categories from one of the below entities are accepted
bull American Board of Medical Specialties wwwabmsorgbull American Midwifery Certification Board wwwamebmidwifeorgbull American Nurses Association wwwanaorgbull American Osteopathic Association wwwosteopathicorgbull The Royal College of Pathologists wwwrcpathorgbull The Royal College of Physicians wwwrcplondonacukbull The College of Family Physicians of Canada wwwcfpccabull Hospital affiliations admittingattending privileges at listed hospitalsbull Board certification including a list of board certification categories as reported by the ABMSbull Medical Group Affiliations including a list of all medical groups with which the physician is affiliatedbull Acceptance of new patientsbull Languages spoken by the physicianbull Office location including physical address and phone number of office locations
Credentialing Policy
The BCBSVT Quality Improvement Credentialing Policy includes details of the credentialing process for hospital based providers credentialing and re‑credentialing criteria verification process quality review and credentialing committee review acceptance to the network ongoing monitoring confidentiality and practitioner rights in the credentialing process The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Providers rights during the credentialing processbull To receive information about the status of the credentialing application Upon request the credentialing coordinator will inform you of the status of
your credentialing application and the anticipated committee review datebull To review information submitted to support the
credentialingre‑credentialing application Upon request you will have the opportunity to review non‑peer protected information in the credentialing file during an agreed upon appointment time The appointment time will be during regular business hours in the presence of the credentialing coordinator
bull To correct erroneousinaccurate information The Plan will notify you in writing if information on the application is inconsistent with information obtained via primary source verification You have the right to correct erroneous information received from verification sources directly with the verifying source You must respond to the Plan in writing to address any conflicting information provided on the application We will review your response to ensure resolution of the discrepancy We evaluate all applications against Plan criteria and may require a credentialing committee review if your application does not meet this criteria
9
Facility Credentialing
The BCBSVT Quality Improvement Policy Facility Credentialing provides the complete details The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or call your provider relations consultant for a paper copy
Reimbursement
We reimburse providers in one of two ways
Fee for Service reimbursement for a service rendered an amount paid to a provider based on the Planrsquos allowed price for the procedure code billed
Capitation a set amount of money paid to a Primary Care Provider or PHO The amount is expressed in units of per member per month (PMPM) It varies according to factors such as age and sex of the enrolled members Primary Care Providers (PCPs) in private or group practices who are under a capitated arrangement will receive a monthly capitated detail report The report is mailed before the 20th business day of every month Each product is issued a separate capitation detail report and check The report lists the members assigned to the PCP and the capitation amount the provider is being paid PMPM
Capitation is paid during the three‑month grace period for individuals covered through the Exchange (prefix ZII) If the member is terminated at the end of the grace period months two and three will be recovered For full details on Grace Periods see Grace Period for Individuals Through the Exchange in Section 6 We use two methods of payment
Paper Check Providers upon effective date of contract are automatically set up to receive weekly paper remittance advice and checks that are mailed using the US postal system
Electronic Payments are the preferred method of payment and offered by BCBSVT providers free of charge Electronic payments offer the following benefits
bull reduces your practice administrative costsbull improves our cash flow and bull makes transactions more secure and safer than paper check
Sign up is easy and done online Simply go to our provider website bcbsvtcomprovider under the Electronic Payment link to learn more and sign up
Please Note Signing up for electronic payment means your Remittance Advice (RA)Provider Vouchers (PV) need to be reviewed printed or downloaded online Your practice will no longer receive paper copies of the RAPV through the US Postal Service
Provider Roles and Responsibilities
Open Communication
BCBSVT and TVHP encourage open communication between providers and members regarding appropriate treatment alternatives We do not penalize providers for discussing medically necessary or appropriate care with members
Conscientious Objections to the Provision of Services
Providers are expected to discuss with members any conscientious objections he or she has to providing services counseling or referrals
Follow-up and Self-care
Providers must assure that members are informed of specific health care needs requiring follow‑up and that members receive training in self‑care and other measures they may take to promote their own health
10
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs) who are then responsible for coordinating the members care PCPs are responsible for requesting any information that is needed from other providers to ensure the member receives appropriate care When a member is referred to a specialist or other provider we require the specialist or provider to send a medical report for that visit to the PCP to ensure that the PCP is informed of the memberrsquos status
We have created and posted a template that can be used to facilitate the communication between behavioral health and primary care providers to assist in patient care coordination for patients receiving mental health or substance abuse services This template is available on our provider website link under provider manual amp reference guide general information communication form for behavioral health and primary care providers
Primary Care Provider Coordinates Care
Except for self‑referred benefits in a managed care plan all covered health services should be delivered by the PCP or arranged by the PCP
The PCP is responsible for communicating to the specialist information that will assist the specialist in consultation determining the diagnosis and recommending ongoing treatment for the patient While none of our Plans (except the New England Health Plan) require referrals we encourage members to coordinate all care through their PCPs
Specialty Provider Responsibilities
Specialty providers are responsible forbull Communicating findings surrounding a patient to the patientrsquos PCP to ensure that the PCP is informed of the memberrsquos statusbull Obtaining prior approval as appropriate
Continuity of Care
BCBSVT and TVHP support continuity of care We allow standing referrals to specialists for members with life threatening degenerative or disabling conditions A specialist may act as a PCP for these members if the specialist is willing to contract as such with the Plan accept the Planrsquos payment rates and adhere to the Planrsquos credentialing and performance requirements A request for a specialist to act as his or her PCP must come from the patient and our medical director must review and approve the request
Providers may contact the customer service unit to initiate a request for a standing referral
A pregnant woman in her second or third trimester who enrolls in a managed care plan can continue with her current provider until completion of postpartum care even if the provider is out of network if the provider agrees to certain conditions
A new member with life threatening disabling or degenerative conditions with an ongoing course of treatment with an out‑of‑network provider may see this provider for 60 days after enrollment or until accepted by a new provider Disabling or degenerative conditions are defined as chronic illnesses or conditions (lasting more than one year) which substantially diminish the personrsquos functional abilities Our medical director must review and approve the request
11
Confidentiality and Accuracy of Member Records
Providers are required tobull Maintain confidentiality of member‑specific information from medical records and information received from other providers This information may
not be disclosed to third parties without written consent of the member Information that identifies a particular member may be released only to authorized individuals and in accordance with federal or state laws court orders or subpoenas Unauthorized individuals must not have access to or alter patient records
bull Maintain the records and information in an accurate and timely manner ensuring that members have timely access to their recordsbull Abide by all federal and state laws regarding confidentiality and disclosure for mental health records medical records and other health and member
informationbull Records must contain sufficient documentation that services were performed as billed on submitted claimsbull Providers are responsible for correct and accurate billing including proper use as defined in the current manuals AMA Current Procedural
Terminology (CPT) Health Care Procedure Coding System (HCPCS) and most recent International Classification of Diseases Clinical Modification (currently ICD 10 CM)
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization) their providers contractors and subcontractors and related entities must provide state and federal regulators full access to records relating to BCBSVT and TVHP members and any additional relevant information that may be required for auditing purposes Medical Record Audits may include the review of financial records contracts medical records and patient care documentation to assess quality of care credentialing and utilization
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to Advanced Benefit Determinations This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to Section 4 ‑ Advanced Benefit Determination for further information
Prior ApprovalReferral Authorization
Participating and network providers are financially responsible for securing prior approvals and referral authorizations before services are rendered even if a BCBSVTTVHP policy is secondary to Medicare For more information on services requiring Prior Approval or referral authorizations please refer to Section 4 Services that deny for lack of prior approval do not qualify for appeal
Billing of Members
Covered Services Participating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members for amounts other than applicable co‑payments coinsurance or deductibles We encourage providers to use their remittance advices to determine member liability for collection of deductibles and coinsurance and to bill members Copayments deductibles and coinsurance however can be billed to the member at the point of service prior to rendering of service(s) In order to bill for these liabilities providers must call our Customer Service Department to ensure the correct collection amount If after receipt of the remittance advice the member liabilities are reduced the provider must provide a quick turn‑around in refunding the member any amounts due
Non-Covered Services In certain circumstances a provider may bill the member for non‑covered services In these cases the collection should occur after you receive the remittance advice which reports the service as non‑covered and shows the amount due from the member
We require that you explain the cost of a non‑covered service to the member and get the memberrsquos signature on an acknowledgement form before you provide non‑covered services
To verify that a service is covered contact the appropriate customer service center
12
Missed Appointments The provider must post or have available to patients the office policy on missed appointments If a member does not comply with the requirement and there is a financial penalty the member may be billed directly A claim should not be submitted to BCBSVT Supporting documentation related to the incident needs to be noted in the members medical records
BCBSVT contracted providers not participating with Medicare (and either accepting or not accepting Medicare assignment) or those who have opted our of Medicare
Providers may participate with BCBSVT but elect not to participate with Medicare or opt out of Medicare In these scenarios determining coverage where a member has Medicare primary coverage and BCBSVT secondary coverage can be complicated Here are some general guidelines
(a) Provider does not participate with Medicare
Some providers chose not to participate with Medicare but will still agree to treat Medicare patients These non‑participating providers may choose to either accept or not accept Medicares approved non‑participating amount for health care services as full payment (also referred to as accepting assignment)
In cases where a provider does not participate with Medicare but does accept assignment the provider agrees to accept the non‑participating allowance as payment in full The provider bills Medicare and Medicare pays 80 of the non‑participating allowance As BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) the claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider A provider may collect from the member any payments Medicare may have made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTs allowed amount
In cases where the provider does not participate with Medicare and does not accept assignment but agrees to treat Medicare patients the provider is permitted to charge an amount up to Medicares limiting charge (Please note that some provider types such as durable medical equipment suppliers are not restricted by the limiting charge) The provider must submit claims for services directly to Medicare on behalf of members Medicare will pay the member 80 of the non‑participating allowance The claim will cross over directly for processing through the BCBSVT system A remittance advice (or provider voucher) and any eligible payments will be made directly to the provider The provider may collect from the member any payments Medicare made directly to the member as well as any member liabilities (under the BCBSVT policy) not collected at the time of service Please note however that for BCBSVT members with carve‑out benefits the ceiling for payment is the difference between what Medicare paid and BCBSVTrsquos allowed amount
The FEP program does not participate in the COBA program The provider should make best efforts to obtain a copy of the Explanation of Medicare Benefits (EOMB) from the member for submission to BCBSVT or to assist the member with the submission of the claim and EOMB to BCBSVT
BCBSVT expects that all contracted providers not participating with Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
(b) Provider has opted out of Medicare
Some provider types may elect to opt out of Medicare An opt‑out provider does not accept Medicare at all and has signed an agreement (sometimes referred to as an affidavit) to be excluded from the Medicare program These providers may charge Medicare beneficiaries whatever they want for services but Medicare will not pay for the care (except in emergencies) Additionally the provider must give the member a private contract describing the providerrsquos charges and confirming the patientrsquos understanding heshe is responsible for the full cost of care and Medicare will not reimburse Finally the provider does not bill Medicare
Providers eligible to opt out include doctors of medicine doctors of osteopathy doctors of dental surgery or dental medicine doctors of podiatric medicine doctors of optometry physician assistants nurse practitioners clinical nurse specialists certified registered nurse anesthetists certified nurse midwives clinical psychologists clinical social workers and registered dieticians
13
and nutrition professionals Providers not eligible to opt out include chiropractors anesthesiologist assistants speech language pathologists physical therapists occupational therapists or any specialty not eligible to enroll in Medicare
In situations where the member has Medicare as primary coverage and a BCBSVT carve‑out policy as secondary coverage and the services at issue are covered by BCBSVT the provider should not collect from the member any amounts that exceed the applicable Copayment Deductible or Coinsurance amounts under the BCBSVT carve‑out policy When billing BCBSVT for a member with a carve‑out policy the provider must submit a copy of the approval of opt‑out letter from Medicare along with the claim form Opt‑out providers must notify their Medicare eligible members prior to services being rendered and must have the member sign a Medicare private contract in which the member agrees to give up Medicare payment for services and pay the provider without regard to any Medicare limits that would otherwise apply to what the provider could charge The member is responsible for anything the BCBSVT carve‑out plan doesnrsquot cover but the provider is bound to accept BCBSVTrsquos allowed amount for covered services as payment in full To the extent the provider charges the member in an amount that exceeds the applicable Copayment Deductible or Coinsurance amounts due under the BCBSVT carve‑out policy the provider must refund the member
BCBSVT expects that all contracted providers opting out of Medicare will follow all applicable Medicare rules including any rules governing interactions with or notices to patients or to BCBSVT
Waivers
Services or items provided by a contractednetwork provider that are considered by BCBSVT to be Investigational Experimental or not Medically Necessary (as those terms are defined in the members certificate of coverage) may be billed to the patient if the following steps occur
1 The provider has a reasonable belief that the service or item is Investigational Experimental or not Medically Necessary because (a) BCBSVT customer service or an eligibility request (using the secure provider web portal or a HIPAA‑compliant 270 transaction) has confirmed that BCBSVT considers the service or item to be Investigational Experimental or not Medically Necessary or (b) BCBSVT has issued an adverse determination letter for a service or item requiring Prior Approval or (c) the provider has been routinely notified by BCBSVT in the past that for members under similar circumstances the services or items were considered Investigational Experimental or not Medically Necessary
2 Clear communication with the patient has occurred This can be face to face or over the phone but must convey that the service will not be reimbursed by their insurance carrier and they will be held financially responsible The complete cost of the service has been disclosed to the member along with any payment requirements and
3 A waiver accepting financial liability for those services has been signed by the member and provider prior to the service being rendered The waiver needs to clearly identify all costs that will be the responsibility of the member once signed the waiver must be placed in the memberrsquos medical records
4 Unless the member chooses otherwise a claim for the service or item must be submitted to BCBSVT This allows the member to have a record of processing for hisher files and if heshe has an HSA or some type of health care spending account to file a claim
After Hours Phone Coverage
BCBSVTTVHP requires that primary care providers (ie internal medicine general practice family practice pediatricians naturopaths qualifying nurse practitioners) and OBGYNs provide 24‑hour seven day a week access to members by means of an on‑call or referral system Integral to ensuring 24‑hour coverage is membersrsquo ability to contact their primary care provider andor OBGYN after regular business hours including lunch or other breaks during the day After‑hours telephone calls from members regarding urgent problems must be returned in a reasonable time not to exceed two hours
Accessibility of Services and Provider Administrative Service Standards
The BCBSVT Quality Improvement Policy Accessibility of Services and Provider Administrative Service Standards provides the complete details on the definition policy methodology for analyzing practitioner performance and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Compliance Monitoring
BCBSVTTVHP monitors access to after‑hours care through periodic audits The plan places calls to providers offices to verify acceptable after‑hours practices are in place The Plan will contact providers not in compliance and will work with them to develop plans of corrective action
14
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring you need to report it to the fraud hotline at (800) 337‑8440 Calls to the hotline are confidential Each call to the hotline is investigated and tracked for an accurate outcome
BCBSVT Audit
The complete Audit Sampling and Extrapolation Policy is available on our provider website at wwwbcbsvtcom
Here is a high level overview
For the purpose of the audit investigation the contemporaneous records will be the basis for the Plans determination If the provider modifies the medical record later it will not affect the audit results Audit findings are based on documentation available at the time of the audit Audit findings will not be modified by entry of additional information subsequent to initiation of the audit for example to support a higher level of coding
Additional clinical information pertinent to the continuum of care that affects the treatment of the patient and to clarify health information may be accepted prior to the closure of the audit and will be reviewed (eg patient intake form labradiology reports)
The Plan reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in Plan policies provider contracts or provider manual If an audit identifies instances of non‑compliance with this payment policy the Plan reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Provider Initiated Audit
Written notification needs to be sent to the assigned provider relations consultant 30 days prior to the audit being initiated The provider relations consultant will contact the provider group and coordinate the details specific to completing the audit such as when it will take place the information required and the required formatting of documents
Access Standards
Primary Care and OBGYN Services
BCBSVTTVHP include the specialties of general practice family practice internal medicine and pediatrics in their definitions of Primary Care Providers BCBSVTTVHP monitors compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance If a provider does not meet one of the below listed standards we will work with the provider to develop and implement an improvement plan The following standards for access apply to care provided in an office setting
bull Access to medical care must be provided 24 hours a day seven days a weekbull Appointments for routine preventive examinations such as health maintenance exams must be available within 90 days with the first
available provider in a group practicebull Appointments for routine primary care (primary care for non‑urgent symptomatic conditions) must be available within two weeksbull Appointments for urgent care must be available within 24 hours (urgent care is defined as services for a condition that causes symptoms of
sufficient severity including severe pain that the absence of medical attention within 24 hours could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the memberrsquos physical or mental health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of any bodily organ or part)
bull Appointments for non-urgent care needs a member must be seen within two weeks of a request (excluding routine preventive care)bull Emergency care must be available immediatelybull Routine laboratory and other routine care must be available within 30 days
If a provider does not meet one of the above standards we work with the provider to develop and implement a plan of correction
15
The BCBSVTTVHP administrative services standards for PCP and OBGYN offices are as followsbull Wait time in the waiting room shall not exceed 15 minutes beyond the scheduled appointment If wait is expected to exceed 15 minutes beyond the
scheduled appointment the office notifies the patient and offers to schedule an alternate appointmentbull Waiting to get a routine prescription renewal (paper or call in to patientrsquos pharmacy) shall not exceed three daysbull Call back to patient for a non‑urgent problem shall not exceed 24 hours
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by specialists (including obstetricians) The Department of Financial Regulation (DOFR) require BCBSVT and TVHP to monitor specialistsrsquo compliance with the standards described below We use member complaints disenrollments appeals member satisfaction surveys and after‑hours telephone surveys to monitor compliance The following standards for access apply to care provided in an office setting
bull Appointments for non‑urgent symptomatic office visits must be available within two weeksbull Appointments for emergency care (ie for accidental injury or a medical emergency) must be available immediately in the providers office or referred
to an emergency facility
If a provider does not meet one of the above standards we work with the provider to develop and implement an improvement plan
Availability of Network Practitioners The BCBSVT Quality Improvement Policy Availability of Network Practitioners provides the definition of the policy including geographic access performance goals travel time specifications number of practitioners linguistic and cultural needs and preferences and how the program is monitored The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
OpeningClosingMoving of Primary Care Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel A PCP may open his or her patient panel by sending a completed Provider EnrollmentChange Form (PECF) If opening your patient panel be sure to include the date you wish to open your panel otherwise we will use the date we received the form
Closing of an Open Physician Panel BCBSVT and TVHP require 60 days notice to close a patient panel You must submit a Provider EnrollmentChange Form The effective date will be 60 days from our receipt of the form BCBSVT andor TVHP will send confirmation of our receipt of your request including the effective date of the change A PCP may not close his or her panel to BCBSVTTVHP members unless the panel is closed to all new patients
PCPs with closed patient panels It is the PCPrsquos responsibility to review the monthly managed care membership report If a member appears as an addition and is not an existing patient notify your provider relations consultant immediately The notification should contain the member ID number and name We will notify the member and ask him or her to select a new PCP
If notification from the PCP does not occur within 30 days the PCP will be expected to provide health care until the member is removed from the providerrsquos patient panel
We will send confirmation to the provider that the member has been removed and the effective date
Moving of an existing Patient Panel When a primary care provider with an established patient panel moves to a new location or practice it is BCBSVTs policy to move the memberspatients with the individual primary care provider as long as there is no interruption in the providers availability to see BCBSVT patients as an in‑network provider If there is a period (even one day) where the provider would not be able to see BCBSVT patients as an in‑network provider BCBSVT will either (1) keep members with the existing practice the PCP left if they have the ability to take on the patients or (2) move the members to a different PCPpractice who is open to new patients and able to take the members on
Provider must be enrolled credentialed and have a contract (or part of a vendorgroup contract) approved by BCBSVT in place to be eligible
16
Examples
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 (Provider established the private practice with BCBSVT and has approval as of 121118) members are moved with the PCP
PCP leaves ABC practice on 121018 and opens a private practice as of 121118 but is not yet approved by BCBSVT members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP leaves ABC practice on 121018 and opens a private practice until 010119 (private practice is established with BCBSVT) members would remain at ABC practice or be moved to another PCP practice with an open panel who can take on the patients
PCP Initiated Member TransferA Primary Care Provider may request to remove a BCBSVT TVHP andor NEHP member from his or her practice due to
bull Repeated failure to pay co‑payments deductibles or other out‑of‑pocket costsbull Repeated missed scheduled appointmentsbull Rude behavior or verbal abuse of office staffbull Repeated and inappropriate requests for prior approval orbull Irreconcilable deterioration of the physicianpatient relationship
The PCP must submit a written request to his or her provider relations consultant clearly defining the reason and documenting concerns regarding the deterioration of the patientphysician relationship and any steps that have been taken to resolve this problem
The PCP should mail the letter to
Attn (your provider relations consultantrsquos name) BCBSVTTVHP PO Box 186 Montpelier VT 05601‑0186
The provider relations consultant and the director of provider relations will review each case considering provider and member rights and responsibilities
If the transfer is approved we will send a letter to the member with a copy to the PCP The member will be instructed to select a new PCP who is not in the current PCPrsquos office The current PCP is expected to provide health care to the departing patient as medically necessary until the new PCP selection becomes effective
If we do not approve the transfer we send the PCP a letter of explanation
17
Transitioning Pediatric PatientsWe know that transitioning your pediatric patient to their future provider for adult care can be an emotional and sensitive issue We offer the following advice and tools to assist you
bull Talk with your patients who are approaching adulthood about the need to select a primary care provider (PCP) Help them to take the next step by recommending several providers You may even be able to provide some inisght into who may be a good fit for them
bull Our Find a Doctor tool can help you or your patient identify appropriate providers who are accepting new patients To access the Find a Doctor tool go to the Blue Cross and Blue Shield of Vermont website at wwwbcbsvtcom and select the Find a Doctor link Once you accept the terms you can search by name location specialty or specific gender of provider
bull Send a letter to your patients with a list of PCPs accepting new patients We offer a customizable letter you can use to help highlight the importance of selecting a new provider and walk the patient through the process This template is available on our provider website at wwwbcbsvtcom
bull Encourage the patients to call BCBSVT directly at the customer service number listed on the back of their identification card for assistance in adding the new PCP to their member profile We also offer an online option they can use to update their PCP by logging into our secure member portal at wwwbcbsvtcom
Notification of Change in Provider andor Group InformationPlease complete a Provider EnrollmentChange Form (PECF) for each of the following changes
bull Patient panel change (for managed care providers only)bull Physical mailing or correspondence addressbull Termination of a provider In place of a PECF we will accept an email for termination of a provider Please see details below in DeletingTerminating a
Provider sectionbull Provider name (include copy of new license with new name)bull Provider specialtybull Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change Form (GPECF) for each of the following changesbull Tax identification number (include updated W‑9)bull Billing national provider identifierbull Physical mailing or correspondence addressbull Group Name
Mental Health and Substance Abuse Clinicians will need to provide an updated Area of Expertise form if there is a change in the type of conditions they are treating
We cannot accept requests for changes by telephone
If you have a change that is not on the list above please provide written notification on practice letterhead Include to BCBSVT andor TVHP the full names and NPI numbers for the group and all providers affected by the change
The forms (PECF GPECF and Area of Expertise) are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
18
Mail your request to
Provider File Specialist BCBSVT PO Box 186 Montpelier VT 05601‑0186
Or fax to (802) 371‑3489
We appreciate your assistance in keeping our records and provider directories up to date Notifying us of changes ensures that we continue to accurately process claims and that our members have access to up‑to‑date directory information
Note Directory updates will occur within 30 calendar days of receipt of notice of change
Taxpayer Identification Number
If your Taxpayer Identification Number changes you must provide a copy of your updated W‑9 We may need to update your provider contract if your W‑9 changes For more information please contact your provider relations consultant at (888) 449‑0443
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time period should suspend their network status
Providers will notify their assigned Provider Relations Consultant when they are leaving and expected date of return During the sabbatical time period the provider will not be marketed in any directories and will have members temporarily reassigned to another in‑Plan provider if a covering provider within their own practice is not identified
Recredentialing will occur during the providersrsquo normal recredentialing cycle The provider should make arrangements to ensure that the CAQH application and other information needed for recredentialing is available and timely If recredentialing is not timely the provider risks network termination
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance notice to BCBSVT andor TVHP If the provider does not have an active National Provider Identifier with BCBSVTTVHP we need the following documents before we can add the provider
bull Provider Enrollment Change Form (PECF)bull Copy of current state licensurebull Any applicable Drug Enforcement Agency certificate (Please note that the DEA certificate for the state in which providers will be conducting business
must be supplied when dispensing andor storing medications in that location)bull Any applicable board certificationbull Copy of liability insurancebull Credentialing via the CAQH process (Please see Enrollment of Providers)bull Mental Health and Substance Abuse Clinicians must attach completed Area of Expertise form
When we receive the required documentation we will activate your provider profile for both BCBSVT and TVHP We will send a letter notifying the provider of his or her addition to the group vendor file The letter will clarify the providerrsquos status with each network and the effective date
Provider Enrollment Change andor Area of Expertise Forms are available on our provider website at wwwbcbsvtcom under Forms Enrollment and Credentialing If you are not able to access the web contact provider enrollment at (888) 449‑0443 option 2 and a supply will be mailed to you
DeletingTerminating a Provider
A provider who leaves a group or private practice must provide advance notice to BCBSVT Notice can be provided through email to providerfilesbcbsvtcom or by completing the terminate provider section of the Provider Enrollment and Change Form (PECF) If you are sending through email be sure to include the providers full name rendering national provider identifier (NPI) and if in
19
a group setting the NPI of the billing group the reason for termination (such as moved out of state went to another practice going into private practice etc) and the termination date If the terminating provider is a primary care provider we will need to know if there is another provider taking on those patients If submitting a PECF follow the instructions on the form
We appreciate your help in keeping our records up to date Notifying us in a timely manner of provider termination ensures access and continuity of care for BCBSVTTVHP members
BCBSVT notifies affected members of a provider termination 30 days in advance of the effective date of termination
You can download a Provider EnrollmentChange Form by logging onto our provider site at wwwbcbsvtcom If you do not have internet access please contact your provider relations consultant for a copy of the form
Utilization Management Denial Notices Reviewer AvailabilityWe notify providers of utilization management (UM) denials by letter Providers are given the opportunity to discuss any utilization management (UM) denial decision with a Plan physician or pharmacist reviewer
All UM denial letters include the telephone number of our integrated health department Providers may call this number if they want to discuss a UM denial with a Plan physician or pharmacist The telephone number is 1‑800‑922‑8778 (option 3) or 1‑802‑371‑3508
Complaint and Grievance Process
Provider-on-Behalf-of-Member Appeal Process
An Appeal may only be filed by a provider on behalf of a Member when there has been a denial of services which are benefit related for reasons such as non‑covered services pursuant to the Member Certificate services are not medically necessary or investigational lack of eligibility or reduction of benefits Before a provider‑on‑behalf‑of member appeal is submitted we recommend you contact the BCBSVT Customer Service Department as most issues can be resolved without an appeal If you proceed with an Appeal there are three levels to the Provider‑on‑behalf‑of‑Member Appeal process
Level 1mdashA First Level Provider-on-Behalf-of-Member Appeal
A first level Provider‑on‑Behalf‑of‑Member Appeal must be filed in writing to
Blue Cross and Blue Shield of Vermont Attn Appeals PO Box 186 Montpelier VT 05601‑0186
The appeal request may also be faxed to (802) 229‑0511 Attn Appeals
The appeal request should include all supporting clinical information along with the Member certificate number Member name date of service in question (if applicable) and the reason for appeal Assuming you have provided all information necessary to decide your grievance the appeal will be decided within the time frames shown below based on the type of service that is the subject of your appeal (grievance)
20
Note You only need to submit any supporting clinical information that has not been previously supplied to BCBSVT All medical notes etc supplied to BCBSVT during prior approval or claim submission process are on file and will be automatically included in the appeal by BCBSVT
bull Grievances related to ldquourgent concurrentrdquo services (services that are part of an ongoing course of treatment involving urgent care and that have been approved by us) will be decided within twenty‑four (24) hours of receipt
bull Grievances related to urgent services that have not yet been provided will be decided within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent mental health and substance abuse services and prescription drugs that have not yet been provided will be decided
within seventy‑two (72) hours of receiptbull Grievances related to non‑urgent services that have not yet been provided (other than mental health and substance abuse services and prescription
drugs) will be decided within thirty (30) days of receipt andbull Grievances related to services that have already been provided will be decided within sixty (60) days of receipt
If the Provider‑on‑Behalf‑of‑Member Appeal is urgent as described above you and the member will be notified by telephone and in writing of the outcome If the appeal is not urgent as described above you and the member will be notified in writing of the outcome If you are not satisfied with the First Level Appeal decision you may pursue the options below if applicable
Level 2mdashVoluntary Second Level Appeal (not applicable to non group)
A Voluntary Second Level Appeal must be requested no later than ninety (90) days after receipt of our first level denial notice If we have denied your request to cover a health care service in whole or in part you as the provider on behalf of member may request a Voluntary Second Level Appeal at no cost to you or the member Level 1 outlines the information that should be included with your appeal review time frames and where the appeal should be sent You and the member or the memberrsquos authorized representative have the opportunity to participate in a telephone meeting or an in‑person meeting with the reviewer(s) for your second level appeal if you wish If the scheduled meeting date does not work for you or the member you may request that the meeting be postponed and rescheduled
Level 3mdashIndependent External Appeal
A provider on behalf of member may contact the External Appeals Program through the Vermont Department of Banking Insurance Securities and Health Care Administration to submit an Independent External Appeal no later than one hundred twenty (120) days after receipt of our first level or voluntary second level (if applicable) denial notice If you wish to extend coverage for ongoing treatment for urgent care services (ldquourgent concurrentrdquo services) without interruption beyond what we have approved you must request the review within twenty‑four (24) hours after you receive our first level or voluntary second level denial notice To make a request contact the Vermont Department of Banking Insurance Securities and Health Care Administration during business hours (745 am to 430 pm EST Monday through Friday) at External Appeals Program Vermont Department of Banking Insurance Securities and Health Care Administration 89 Main Street Montpelier VT 05620‑3101 telephone (800) 631‑7788 (toll‑free) If your request is urgent or an emergency you may call twenty‑four (24) hours a day seven (7) days a week including holidays A recording will tell you how to reach the person on call If your request is not urgent the Department will provide you with a form to submit your request
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in writing using the BlueCard Provider Claim Appeal Form located on the Provider Website under resourcesformsBlueCard Claim Appeal If the form is not submitted the request will not be considered an Appeal The request will not be filed with the home plan but rather returned to you You will be informed of the decision in writing from BCBSVT Please note the form requires the memberrsquos consent prior to submission Some Blue Plans may also require the member to sign an additional form specific to their Plan before starting the appeal process
When a Member Has to Pay
If a memberrsquos appeal is denied they must pay for services we donrsquot cover
21
Health Insurance Portability and Accountability Act (HIPAA) ResponsibilitiesBCBSVT TVHP and its contracted providers are each individually considered ldquoCovered Entitiesrdquo under the Health Insurance Portability and Accountability Act Administrative Simplification Regulations (HIPAA‑AS) issued by the US Department of Health and Human Services (45 CFR Parts 160‑164) BCBSVT TVHP and contracted providers shall by the compliance date of each of the HIPAA‑AS regulations have implemented the necessary policies and procedures to comply
For the purposes of this Section the terms ldquoBusiness Associaterdquo ldquoCovered Entityrdquo ldquoHealth Care Operationsrdquo ldquoPaymentrdquo and ldquoProtected Health Informationrdquo have the same meaning as in 45 CFR 160 and 164
Disclosure of Protected Health Information
From time to time BCBSVT or TVHP may request Protected Health Information from a provider for the purpose of BCBSVT andor TVHP Payment and Health Care Operations functions including but not limited to the collection of HEDIS data Upon receipt of the request the provider shall disclose or authorize its Business Associate who maintains Protected Health Information on its behalf to disclose the requested information to BCBSVTTVHP as permitted by the HIPAA‑AS at sect 164506
The provider is not required to disclose Protected Health Information unless
A BCBSVT andor TVHP has or had a relationship with the individual who is the subject of such information and
B The Protected Health Information pertains to that relationship and
C The disclosure is for the purposes ofbull The Payment activities of BCBSVT andor TVHPbull Conducting quality assessment or quality improvement activities including outcomes evaluation and development of clinical guidelinesbull Population‑based activities relating to improving health or reducing health care costs protocol development case management and care
coordination contacting health care providers and patients with information about treatment alternatives and related activities that do not include treatment
bull Reviewing competence or qualifications of health care professionals evaluating practitioner and provider performance health plan performancebull Accreditation certification licensing or credentialing activities
BCBSVT andor TVHP will limit such requests for Protected Health Information to the minimum amount of Protected Health Information necessary to achieve the purpose of the disclosure
Business Associates
Providers are required to provide written notice to BCBSVT or TVHP of the existence of any agreement with a Business Associate including but not limited to a billing service to which Provider discloses Protected Health Information for the purposes of obtaining Payment from BCBSVT andor TVHP
The notice to BCBSVTTVHP regarding such agreement shall at a minimum includebull the name of the Business Associatebull the address of the Business Associatebull the address to which the BCBSVT andor TVHP should remit payment (if different from the Providerrsquos office)bull the contact person if applicable
Upon receipt of notice BCBSVT andor TVHP will communicate directly with Business Associate regarding Payment due to Provider
22
Provider must notify BCBSVT andor TVHP of the termination of the Business Associate agreement in writing within ten (10) business days of termination of the Business Associate agreement BCBSVTTVHP shall not be liable for payment remitted to Providerrsquos Business Associate prior to receipt of such notification Notifications should be sent to
Blue Cross and Blue Shield of Vermont Attn Privacy Officer PO Box 186 Montpelier VT 05601‑0186
Standard Transactions
The provider and BCBSVTTVHP shall exchange electronic transactions in the standard format required by HIPAA‑AS Questions regarding the status of HIPAA Transactions with BCBSVTTVHP should be directed to the E‑Commerce Support Team at (800) 334‑3441
Member Rights and ResponsibilitiesClick here for full details and link to the URL httpwwwbcbsvtcommembermember-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy PracticesWe are required by law to maintain the privacy of our membersrsquo health information by using or disclosing it only with the memberrsquos authorization or as otherwise allowed by law Members have the right to information about our privacy practices A complete copy of our Notice of Privacy Practices is available at wwwbcbsvtcomprivacyPolicies or to request a paper copy contact the Provider Relations Department at (888) 449‑0443
23
Section 2Blue Cross and Blue Shield of Vermont WebsiteThe Blue Cross and Blue Shield of Vermont (BCBSVT) website located at wwwbcbsvtcomprovider uses (128‑bit encryption as well as firewalls with built‑in intrusion detection software In addition we maintain security logs that include security events and administrative activity These logs are reviewed daily)
Our provider website has a general area that anyone can access and a secure area that only registered users can access
The general area of the provider website contains information about doing business with BCBSVT such as recent provider mailings news from BCBSVT forms medical policies provider manual tools and resources
The secure area of the provider website contains information such as eligibility benefits and claim status for BCBSVT FEP and BlueCard members To become a registered user you will need to work with your local administrator (this is a person in your organization who has already agreed to oversee the activities related to addingdeleting staff and assigning roles and responsibilities for your organization) If your organization does not already have a local administrator click on the secure area of the provider website and follow the instructions to register as a new user
We have a Provider Resource Center Reference Guide available on our website at wwwbcbsvtcomprovider under the link Provider Manual amp Reference Guides This guide provides information on how to create an account maintain users and use the eligibility claim look‑up ClearClaim Connect and on line prior approval functionality
Questions related to the website can be directed to the provider relations team at (888) 449‑0443
How to Review Coverage History on the Web
The eligibiity functionality on the secure provider website does allow providers to view previous BCBSVT coverage history for members for up to 18 months as long as the member is still on an active BCBSVT policy
If a member is terminated with BCBSVT you will not be able to locate any eligiblity information on the web
There are two ways to review previous membership If you know a member had previous coverage and is still active you can complete a search using either ID or name and change the ldquoAs ofrdquo date to the date of coverage you are looking for
24
This will bring you to that member selection or a list of members Click on the member you want to review (by clicking on their name highlighted in blue)
This will provide the details of the policy active during that time period If you scroll to the bottom (titled Benefit Plan Information) you will see the effective dates of that specific policy
25
Or the second option If you do not know whether the member had previous coverage
Enter the memberrsquos identification number or name using the EligibilityBenefits link It will automatically default to the current date
Depending on how you search you will either get a list or that specific member Click on the memberrsquos name (highlighted in blue) This will bring you to the page below
26
Click on View History which will give you a listing of previous dates of coverage (if applicable)
If you want the specific details of the coverage and benefits go back to the elligibility look up and change the ldquoAs ofrdquo date for the member
27
Section 3MandatesAdministrative Service Only (ASO) employer groups have the ability to include or exclude state mandates requiring coverage for certain types of services or for services rendered by certain provider types Below are some examples
bull Services provided by Athletic Trainersbull Autism Servicesbull Services provided by Chiropractorsbull Services provided by Naturopaths
You should always verify a members benefits prior to rendering services As a reminderbull When calling customer service team for eligibility make sure you identify the type of provider who will be rendering the service even if you think it is
obviousbull When using the provider resource center for eligibility verification
bull Athletic Trainers and Naturopaths Before the Eligibility Detail look for the following message ldquoNOTE this plan provides no benefits for services performed by an athletic trainer or naturopathrdquo
bull Autism Services Coverage information is contained within the memberrsquos certificate of coverage which is located as a link after the eligibility verification
bull Chiropractic Services Chiropractic benefit information will not appear in the eligibility verification
Member AccumulatorsMembers have specific dates when their deductibles out‑of‑pocket limits and other totals begin to accumulate They then run for a 12‑month period before resetting Our member accumulators can be either on a calendar year or plan year
On a calendar year schedule the deductible and other benefit totals start to accumulate on January 1 regardless of enrollment or renewal date
On a plan year schedule the deductible and other benefit totals start to accumulate on the effective or renewal date which can be any time of the year They reset annually on the renewal date
Examples of benefits affected by plan or calendar year accumulators (this list may not be inclusive and in some cases benefits may be limited to only certain products)
bull Deductiblesbull Out‑of‑pocket maximumsbull Physical medicine occupational therapy andor speech therapy limitsbull Chiropractic visit limit (before we require prior approval)bull Nutritional counseling visit limitsbull Annual vision exam eligibility (if the member has the benefit)bull Private duty nursing
Vermont Health Connect members (those with federal qualified health plans) which have a prefix of ZII (non‑group) or ZIG (small group) are based on a calendar year
Large group employers have the option to select a calendar or plan year accumulators so they will vary
Itrsquos very important when verifying eligibility that you verify when the membersrsquo accumulators begin and reset
28
Member EligibilityMember eligiblity can be verified by using our Provider Resource Center located at wwwbcbsvtcomprovider You must have a user name and password to view the information Full details on requirements and how to obtain a password are available on the ldquolog inrdquo page
There are two web‑based options available Eligibility Search and Realtime Eligibility Search The Eligibility Search feature provides information on members covered by BCBSVT The Realtime Eligibility Search provides information on all Blue Plan members including BCBSVT and Federal Employee Program members Full details on the BlueCard (Blue Plan members) program are available in Section 8 of the provider manual
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
When billing BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
We anticipate the issue will be corrected in mid‑2017
We also have customer service teams that can assist you over the phone if you are not able to utilize the web‑based searches Click here for a listing of contacts and number(s) to call for assistance
Regardless of which method you use to verify member eligibility you will need to have key information availablebull Patient Name (first and last)bull Patient Date of Birth (month day and year)bull Patient identification number BCBSVT members have an alpha prefix consisting of three letters plus nine digiits starting with an 8 FEP members
have the letter R as their prefix followed by eight digits BlueCard members have a 3‑letter prefix followed by an ID code These codes are of varying lengths and may consist of all numerals all letters or a combination of both
For a real time search in our provider resource center some additional information is requiredbull Subscriber Name (first and last)bull Subscriber Date of Birth (month day and year)bull Requesting Provider (name or NPI)
Alpha prefixes are not Blue Plan specific For a listing of BCBSVT NEHP and CBA Blue prefixes click here
Member Certificate ExclusionsOur membersrsquo certificates of coverage and riders contain a section on general exclusions which are services that even if medically necessary are not eligible for reimbursement Included among these general exclusions are services prescribed or provided by a
bull Provider that we do not approve for the given service or who is not defined in our ldquoDefinitionsrdquo section as a providerbull Professional who provides services as part of his or her education or training programbull Member of your immediate family or yourselfbull Veterans Administration Facility treating a service‑connected disabilitybull Non‑Preferred Provider if we require use of a Preferred Provider as a condition for coverage under your contract
If you have questions regarding benefit exclusions please contact our customer service department or your provider relations consultant
Member Confidential CommunicationsAt times our members may not be in a safe situation and may require that communications related to their care be handled in a more sensitive manner
For these situations Blue Cross and Blue Shield of Vermont (BCBSVT) members have the ability to file for a confidential communication process
29
The below processes only apply to BCBSVT and Vermont Health Plan members Members of any other Blue Plan need to have requests filed with their home plans
There are two types of confidential communication processbull Standard Confidential Communicationbull Confidential Communication for Sexual Assault (or other expedited matters)
Standard Confidential CommunicationThe member uses a Form F14 Confidential Communication Request A copy of the form is available on our website at wwwbcbsvtcom
Completed request forms for confidential communication can be faxed directly to the BCBSVT legal department secure fax line at (866) 529‑8503 or mailed to the attention of the privacy officer BCBSVT PO Box 186 Montpelier VT 05602 or faxed to our Customer Service department (802) 371‑3658 The requests will be reviewed and processed within 30 days
Confidential Communication for Sexual AssaultAt times Vermont SANE (sexual assault nurse examiners) help facilitate the confidential communication process for Vermont sexual assault crime victims The nurse may submit the Vermont Center for Crime Victim Services confidential communication form or the BCBSVT confidential communication form
These requests can be submitted using Form F14 Confidential Communication Request or the Vermont Center for Crime Victim Services Confidential Communication form If you are using Form F14 please clearly note that it is related to sexual assault
Forms can be faxed to the Legal Department (866) 529‑8503 or the Customer Service department (802) 371‑3658
It is very important to include on the form or the fax cover sheet a contact personrsquos name and direct phone number for BCBSVT to follow up with questions or status on processing the request
Confidential communications received for sexual assault cases are expedited because of the nature of the services and so that claims donrsquot get submitted and processed before BCBSVT gets the memberrsquos Summary of Health Plan re‑directed or member resource center access revoked
Facilities andor providers working with the members on this process need to have a strong process in place to notify your billing staff and have all claims submissions placed on hold until BCBSVT has confirmed the process is complete and claim (s) are ready to be submitted
For these expedited cases the legal team will acknowledge receipt of the forms and inform the submitter that the set up is complete and claims can be submitted
Member Identification CardsBlue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) issue identification cards to all members Providers should periodically ask to see the memberrsquos identification card and keep a photocopy of it on file Important information is often printed on the back of the card and in some cases failure to comply with requirements described on the card may result in a reduction of the memberrsquos benefits
Please note BCBSVT is in the process of moving from Account Numbers to Group Numbers for employer groups
During this transition you may find that the Group Number listed on a memberrsquos identification card is not the same number that appears during an on‑line eligibility look up or a HIPAA compliant 270271 transaction
30
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
When billling BCBSVT you can report either number BCBSVT does not use this information when validating the memberrsquos coverage or eligibility for claim processing
New identification cards are issued to members whenever there is a change inbull Benefitsbull Membershipbull Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer
The easy‑to‑find alpha prefix identifies the memberrsquos Blue Cross and Blue Shield Plan
The BlueCard suitcase logo may appear anywhere on the front of the ID card
Accountable Blue
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
AccountableBlue
ACP 101 ACP 102
PREVENTIVE $ 0PCP $XXSPECIALIST $XXSPECIALIST ACCT BLUE $XXEmERgENCy Room $XX
Please refer to your Contract for complete information
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
your Accountable Blue Team (Acct Blue) includes the CVmC medical Staff along with other central Vermont providers For a complete listing visit wwwbcbsvtcomacctblue
group Number 123456789BCBS PLAN 415915Rx group VT7AEffective Date mmddyyyy
SubscriberJohn SubscriberID ZIA123456789
member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494outside of Area (800) 810-2583mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Pharmacy benefits manager
Blue Cross and Blue Shield of VermontPo Box 186montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Blue Card
See Section 7 for a sample BlueCard ID card
Indemnity (Fee-for-Service)
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
CompPlan
ndash Page 1 ndash
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
Comp 301Comp 102
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
31
University of Vermont Open Access Plan
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
ndash Page 1 ndash
OpenAccess
Plan
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
wwwbcbsvtcomuvmcarebcbsvtcomCustomer Service (888) 222-7886Provider Service (888) 222-7886Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (888) 222-7886Report a hospital admission or surgery (888) 222-7886Pharmacy (877) 493-1950
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures and prescription drugs Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Office Visit $20
UVM 501 UVM 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
Pharmacy benefits manager
Vermont Blue 65 (formerly known as Medi-Comp)
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
ndash Page 28 ndash
VermontBlue 65
Group Number 12345678BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
FMEDI - LMEDI1 - BMEDI
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Pharmacy (877) 493-1947
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
SubscriberJohn SubscriberID XYZ123456789
Pharmacy benefits manager
Member 03Jane Smith
Vermont Freedom Plan PPO (VFP)
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
VermontFreedom
Plan
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 247-2583Provider Service (800) 924-3494Outside of Area (800) 810-2583Inpatient Preadmission Admission Review (800) 922-8778Pharmacy (877) 493-1947
Free 101Free 202
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An independent licensee of the Blue Cross and Blue Shield Association
Refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
OffICE VISIT $20EMERGENCy $50
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane Smith
Pharmacy benefits manager
ndash Page 6 ndash
The Vermont Health Plan (TVHP)
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
The VermontHealthPlan
TVHP 101TVHP 102
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
PREVENTIVE OffICE $0OffICE VISIT $20SPECIALIST $30INPATIENT HOSPITAL $500OuTPATIENT SuRGERy $200EMERGENCy ROOM $100
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (888) 882-3600Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356Pharmacy (877) 493-1947
The Vermont Health Planis a controlled affiliate ofBlue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186 Independent licensees of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
All services delivered outside The Vermont Health Planrsquos network require Prior Approval you do not need Prior Approval if your condition meets our definition of an Emergency Medical Condition
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Group Number 123456789BCBS PLAN 415915Rx Group VT7AEffective Date mmddyyyy
Pharmacy benefits manager
ndash Page 10 ndash
Vermont Health Partnership (VHP)
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
ndash Page 14 ndash
VermontHealth
Partnership
VHP 201 VHP 202
OffICE VISIT $10SPECIALIST $20INPATIENT HOSPITAL $250OuTPATIENT SuRGERy $100EMERGENCy ROOM $50
wwwbcbsvtcomcustomerservicebcbsvtcomCustomer Service (800) 344-6690Provider Service (800) 924-3494Outside of Area (800) 810-2583Mental Health and Substance Abuse Treatment Prior Approval (800) 395-1356
Blue Cross and Blue Shield of VermontPO Box 186Montpelier VT 05601-0186An Independent licensee of the Blue Cross and Blue Shield Association
Please refer to your Contract for complete information
Providers outside Vermont should file claims with their local Blue Cross and Blue Shield Plans
Prior approval is necessary for certain procedures Visit wwwbcbsvtcom or call customer service for the list and instructions for requesting prior approval
Group Number 123456789BCBS PLAN 415915Effective Date mmddyyyy
SubscriberJohn SubscriberID XYZ123456789
Member 03Jane SmithPrimary Care PhysicianJ Q Careprovider
32
Member Proof of InsuranceMembers who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan addition of member to policy etc) are able to print a ldquoproof of insurancerdquo document from the member website Below is an example of this document
This document serves as proof of insurance until the identification card is received by the member It provides the details your practice will need to verify a memberrsquos eligibility and benefits on the secure provider website at wwwbcbsvtcom or by calling the customer service team
Dear NAME
NAME ltBookmark First and Last Namegt DOB 00000000
MEMBER ID USID GROUP ltBookmark Group Namegt GROUP NO ltBookmark Group Numbergt
PLAN CODE 415915 PHARMACY Details provided in table below
Certification of Health Plan Coverage
If you donrsquot have your ID card you may use this form as temporary proof of coverage subject to the terms and conditions of your Certificate of Coverage and your contract documents
1 Name(s) of any members to whom this certificate applies
2 Name and address of plan administrator or insurer responsible for providing this certificate
Blue Cross Blue Shield of Vermont PO Box 186 Montpelier VT 05601‑0186
3 Customer Service Team (800) 247‑2583
4 Pre‑Admission Review (800) 922‑8778
PHARMACY DETAILS Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card
Please note if you have Medicare Part D coverage your group may have elected you to have your benefits managed by Blue MedicareRxSM Please see your separate pharmacy ID card
If Prefix is Pharmacy Group Number is Contact NumberDVT EVT FVT FAC FAH FAO See pharmacy ID card See pharmacy ID cardZIB VT7A (Express Scripts) ‑ Discount only (877) 493‑1947ZIA ZID ZIE ZIF ZIH ZIJ ZIK ZIL ZIU ZIV VT7A (Express Scripts) (877) 493‑1947ZIG ZII L4FA (Express Scripts) (877) 493‑1947
Member Name Coverage Start Date Coverage End Date
33
If your coverage has ended and you wish to get new coverage there may be a time limit on when you may do so without being required to wait for an open enrollment period This period of time can be as little as 30 days from the triggering event causing you to lose coverage For more information about special enrollment periods and applicable deadlines please contact
bull your new employer if you will get your coverage through work orbull Vermont Health Connect if you will purchase coverage outside of work (855) 899‑9600
You can use this form for proof of coverage if your new coverage requires that you had previous coverage within a certain time period
If you have questions or concerns you may contact our customer service team toll‑free at (800) 247‑2583 Wersquore in the office Monday through Friday from 7 am to 6 pm except holidays You may also send us a secure message through our Member Resource Center online by logging into your account at wwwbcbsvtcomMRC
Thank you for choosing Blue Cross and Blue Shield of Vermont for your health and wellness benefits We look forward to serving you
34
Section 4Medical Utilization Management (Care Management)The Blue Cross and Blue Shield of Vermont integrated health department performs focused medical utilization review for selected inpatient and outpatient services Medical utilization management is part of the overall Blue Cross and Blue Shield of Vermont care management program
The focused inpatient utilization is based on an analysis of the individual hospitalrsquos utilization and practice patterns and may vary by provider Utilization patterns at the network hospitals are reviewed quarterly As utilization patterns change the Plan evolves the focus of the inpatient utilization review process Clinicians conduct telephonic review on those inpatient cases that meet the focus criteria for that quarter
Integrated health staff also review targeted outpatient procedures and services through the prior approval process
Clinicians are authorized to grant approval for services that meet plan guidelines and deny services excluded from the benefit plan A plan physician makes all denial decisions that require an evaluation of medical necessity
Components of the medical utilization management program includebull Pre‑notification of admissionsbull Prior approvalPre‑servicebull Concurrent reviewbull Retrospective reviewPost‑servicebull Discharge planning in collaboration with facilities members and providersbull Medical claim review
BCBSVT provides members providers and facilities access to a toll‑free number for utilization management review The utilization management staff of the integrated health department is available to receive and place calls during normal business hours (8 am to 430 pm Monday through Friday) Integrated health management staff do not place outgoing calls after normal business hours In addition members andor providers who need to contact the Plan after normal business hours may utilize the toll free number and leave a voice message related to non‑urgentnon‑emergent care Information may also be sent via fax or Web at any time with the ability to attach clinical information with the request All inquiries received after hours will be addressed the next business day For urgent or emergent care a clinician and physician are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations When speaking with others the integrated health staff identify themselves by name title and as an employee of Blue Cross and Blue Shield of Vermont All inquiries related to specific UM cases are forwarded to integrated health staff for resolution regardless of where the initial inquiry was received within the Plan
Case managers collect data on all case‑managed cases including the followingbull Age of memberbull Previous medical history and diagnosisbull Signs and symptoms of their illness and co‑morbiditiesbull Diagnostic testingbull The current plan of carebull Family support and community resourcesbull Psychosocial needsbull Home care needs if appropriatebull Post‑hospitalization medical support needs including durable medical equipment special therapy and medicationsinfusion therapy
35
The following information sources are considered when clinicians perform utilization management reviewbull Primary care provider andor attending physicianbull Member andor familybull Hospital medical recordbull Milliman Health Care Management Guidelines Inpatient and Surgical Care and Ambulatory and Recovery Facility Guidelinesbull Blue Cross and Blue Shield of Vermont medical policiesbull Blue Cross and Blue Shield Association medical policiesbull Board‑certified specialist consultantsbull TEC (Technology Evaluation Center) assessmentbull Health care providers involved in the memberrsquos carebull Hospital clinical staff in the utilization and quality assurance departmentsbull Plan medical director and physician reviewers
A more intensive review occurs for some requested procedureservice(s) based on the need to direct care to specific providers coverage issues or based on quality concerns about the medical necessity for the requested procedureservice(s) A more intensive review may require office records andor additional medical information to support the request The services which require additional medical information include but are not limited to
bull Possible cosmetic procedures eg breast reductionbull Organ transplantsbull Out‑of‑network for point of service product(s) and managed productsbull Experimental proceduresprotocols
Individual member needs and circumstances are always considered when making UM decisions and are given the greatest weight if they conflict with utilization management guidelines In addition both behavioral and medical staff consider the capability of the Vermont health care system to actually deliver health services in an alternate (lesser) setting when applying utilization management criteria If the requested services do not meet the Planrsquos criteria clinical staff documents the memberrsquos clinical needs and circumstances and any limitations in the delivery system and forward that information to a medical director for a decision
Utilization Review Process
The utilization review clinician may contact the facility utilization review staff andor the attending provider to obtain the clinical information needed to approve services However if the utilization review clinician cannot obtain sufficient information to determine the medical necessity appropriateness efficacy or efficiency of the service requested andor the review is unresolved for any other reason the Planrsquos clinical reviewer refers the case to a Plan provider reviewer
The Planrsquos provider reviewer considers the individual clinical circumstances and the capabilities of the Vermont community delivery system for each case In making the final determination the actual clinical needs take precedence over published review criteria In the event of an adverse decision both the member and participating provider can request an appeal The appeal procedure is documented more specifically later in this document
During the concurrent review process if services or treatments are provided to the member that were not included in the original request and are determined to be not medically necessary the Plan may deny those services or treatments and the member is not to be held liable This means that the member is not penalized for care delivered prior to notification of an adverse determination For further details see provider contracts
BCBSVT utilization staff will not accept any financial incentive relating to UM decisions
36
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy Clinical Practice Guidelines provides the details on the policy policy application and annual review criteria The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally accepted medical and scientific evidence and that are consistent with clinical practice parameters as recognized by health professionals in the specialties thatas typically provide the procedure or treatment or diagnose or manage the medical condition Such guidelines include nationally recognized health care guidelines MCG Level of Care utilization System (LOCUS) Child and Adolescent Level of Care Utilization (CALOCUS) and the American Society of Addiction Medicine (ASAM) criteria
In addition to the national guidelines mentioned above the Planrsquos internal medical policy and the Blue Cross and Blue Shield Association Medical Policy andor the TEC Assessment Publications are utilized as resources to reach decisions on matters of medical policy benefit coverage and utilization management
The Blue Cross and Blue Shield Association Medical Policy Manual provides an informational resource which along with other information a member Blue Cross and Blue Shield plan (and its licensed affiliates) may use to
bull Administer national accounts as they may decide to have their employee benefit coverage so interpretedbull Assist the Plan in reaching its own decisions on matters of subscriber coverage and related medical policy utilization management managed care and
quality assessment programs
These guidelines are reviewed on an annual basis by the clinical advisory committee to assure relevance with current practice taking into account input from practicing physicians psychiatrists and other health providers including providers under contract with the Plan if applicable and are available to all providers under contract with the Plan as well as to members and their treating providers upon request
Providers and members may request a copy of the applicable criteria from the integrated health management department by facsimile (802) 371‑3491 phone (800) 922‑8778 option 1 or mail at BCBSVT PO Box 186 Montpelier VT 05601‑0186
The Plan has adopted the nationally recognized guidelines for the treatment of Congestive Heart Failure Chronic Obstructive Pulmonary Disease Substance Use Disorders
Clinical Practice Guidelinesbull Evaluation and Management of Congestive Heart Failure in the Adult American College of Cardiology and American Heart Association
wwwcardiosourceorgbull Global Initiative for Chronic Obstructive Lung Diseasemdasha Pocket Guide to COPD Diagnosis Management and Prevention a Guide for Health Care
Professionals wwwgoldcopdorgbull Treating Patients with Substance Use Disorders Alcohol Cocaine and Opioids American Psychiatric Association
wwwpsychiatryonlinecompracGuidepracGuideTopic_5aspxbull Treating Major Depression American Psychiatric Association wwwpsychiatryonlinecompracGuidepracGuideTopic_7aspx
37
The Plan has adopted nationally recognized preventive health and clinical practice guidelines for Adult and Pediatric Preventive Immunizations Adult and Children and Adolescent Clinical Preventive Services and treatment of Substance Abuse Opioid Abuse and Depressive Disorder Nationally recognized experts developed these guidelines The guidelines are available for you to read or print on the following websites
bull Adult Preventive Immunization Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpadulthtmlbull Pediatric Preventive Immunizations Centers for Disease Control and Prevention wwwcdcgovvaccinesscheduleshcpchild‑adolescenthtmlbull USPSTF Recommended Adult Preventive Guidelines US Preventive Services Task Force wwwuspreventiveservicestaskforceorguspstopicshtmlbull USPSTF Recommended Preventive Guidelines for Children and Adolescents US Preventive Services Task Force
wwwuspreventiveservicestaskforceorgtfchildcathtmlbull Guidelines for the Treatment of Patients with Substance Abuse Opioid Abuse American Psychiatric Association httppsychiatryonlineorgguidelines
aspxbull Guidelines for Treatment of Patients with Depressive Disorder American Psychiatric Association httppsychiatryonlineorgguidelinesaspx
In addition to the nationally recognized preventive health and clinical practice guidelines listed above BCBSVT bi‑annually adopts new clinical practice guidelines and reviews clinical guidelines that the Plan previously adopted The Plan has adopted guidelines for the treatment of Chronic Heart Failure Chronic Obstructive Pulmonary Disease Diabetes Asthma Overweight and Obesity and Hypertension The guidelines may be evidence‑based guidelines or consensus guidelines developed by providers These guidelines are available at wwwbcbsvtcomproviderreference‑guidesclinical‑practice‑guides by calling Customer Service at (800) 924‑3494 or by emailing customerservicebcbsvtcom
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationrdquo This allows members and providers to submit a written request asking about benefit availability for specific services and receive a written response
You can use the prior approval form for submission of FEP advanced benefit determinations but you will need to clearly mark the form (preferably at the top) ldquoAdvanced Benefit Determinationsrdquo
If the prior approval form is not clearly marked it will be assumed you are submitting for prior approval only
A complete list of services requiring prior approval for FEP members is available on our provider website at wwwbcbsvtcomprovider under the Prior ApprovalPre‑NotificationPre‑Service request link
Prior ApprovalReferral Authorization (referral authorizations are only required for members with the New England Health Plan)
Prior approvalreferral authorization is required for coverage of selected supplies procedures and pharmaceuticals before services are rendered as outlined in member certificates and outlines of coverage Even members with BCBSVTTVHP as a secondary carrier including those with Medicare as the primary carrier need to obtain a prior approval for applicable services These lists are updated annually based upon Vermont practice patterns The current lists are available on the provider resource center located at wwwbcbsvtcom Requests for prior approvalreferral authorization can be submitted by phone mail fax or (Web to Integrated Health) at the Plan utilizing the appropriate form for supplies and procedures or pharmaceuticals These prior approvalreferral authorization requests may come from the referring provider the servicing provider or the member Forms can be obtained from the provider resource center located at wwwbcbsvtcom or by calling customer service
Note Referral authorizations for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Planrsquos prior approvalreferral authorization guidelines will apply and requests need to be submitted directly to that Plan
Prior approvalreferral authorization requests are reviewed by a Plan clinician a PlanTVHP medical director a Plan contract dentist reviewer a Plan pharmacist reviewer or a Care Advantage Inc (CAI) consultant medical director The clinician may approve services but does not issue medical necessity denials The dentist and pharmacist reviewers only review requests pertinent to their disciplines Determinations to deny or limit services are only made by physicians under the direction of the medical director
Upon receipt the reviewer evaluates the prior approval request If insufficient information is present for determination additional information is requested in writing from the member or provider The notice of extension specifically describes the required information The member or provider is afforded at least 45 calendar days from receipt of the notice within which to provide the specified
38
information If no additional information is received the Plan will deny the request for benefits as not medically necessary based on the information previously received and the charges may be denied when claims are submitted without prior approval
Once the information is sufficient for determination the registered clinical reviewer approves requests that meet pre‑established medical necessity criteria and are covered benefits If medical necessity criteria are not met the registered clinical reviewer refers the case to a Plan medical director for decision The physician reviewer may request additional information or contact the requesting physician directly to discuss the case Appropriate clinical information is collected and a decision formulated based on adherence to nationally accepted treatment guidelines and unique individual case features References used to make determination include but are not limited to the following
bull Blue Cross and Blue Shield Association TEC Assessmentbull Blue Cross and Blue Shield Association Medical Policy Manualbull Blue Cross and Blue Shield of Vermont Medical Policy Manualbull Medical director review of current scientific literaturebull Review of specific professional medical and scientific organizations (ie SAGES)bull Milliman Care Guidelines Current Edition
Once a determination is made the member provider and the referred‑to‑provider are notified in writing for approvals and denials Decision letters contain the following
bull A statement of the reviewers understanding of the requestbull If applicable a description of any additional material or information necessary for the member to perfect the request and an explanation of why such
material or information is necessarybull If the review resulted in authorization a clear and complete description of the service(s) that were authorized and all applicable limits or conditionsbull If the review resulted in adverse benefit determination in whole or in part
bull The specific reason for the adverse benefit determination in easily understandable languagebull The text of the specific health benefit plan provisions on which the determination is basedbull If the adverse benefit determination is based on medical necessity an experimentalinvestigational exclusion is otherwise an appealable decision
or is otherwise a medically‑based determination an explanation of the scientific or clinical judgment for the determination and an explanation of how the clinical review criteria and the terms of the health benefit plan apply to the memberrsquos circumstances
bull If an internal rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination either the specific rule guideline protocol or other similar criterion or a statement that such a rule guideline protocol or other similar criterion was relied upon in making the adverse benefit determination and that a copy of such rule guideline or protocol or other criterion will be provided to the member upon request and free of charge within two business days or in the case of concurrent or urgent pre‑service review immediately upon request
bull If the review is concurrent or pre‑service what if any alternative covered benefit(s) the Plan will consider to be medically necessary and would authorize if requested
bull A description of grievance procedures and the time limits applicable to such proceduresbull In the case of a concurrent review determination or an urgent pre‑service request a description of the expedited grievance review process that
may be applicable to such requestsbull A description of the requirements and timeframes for filing grievances andor a request for independent external review in order for the member
or provider to be held harmless pending the outcome where applicablebull Notice of the right to request independent external review after a grievance determination in the language format and manner prescribed by the
Department andbull Local and toll free numbers for the departmentrsquos health care consumer assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business the Plan adheres to Vermont Rule H2009‑03 NCQA accreditation and federal timeliness standards For non‑urgent pre‑service review decisions the Plan must provide written notice of adverse determination to the member and treating provider (if known) within a reasonable period not longer than two business days after receipt of the request Verbal notification must be given to the member and treating provider (if known) with written notification sent within 24 hours of verbal notification
39
If additional information is needed because of lack of information submitted with the prior approval request the Plan sends a written request for additional information within two business days of receipt of the request The notice of extension specifically describes the required information The member or provider has at least 45 calendar days from receipt of the notice within which to provide the specified information
The Plan does not retroactively deny reimbursement for services that received prior approval except in cases of fraud including material misrepresentation See provider contracts for more complete details
Note Dental prior approval for (1) Health Exchange pediatric members or (2) members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT and are eligible through the BCBSVT Dental Medical policy ldquoPart Brdquo are reviewed by CBA Blue See Dental Care in Section 6 for more details
Pharmacy prior approvals are reviewed by Express Scripts Inc (ESI) Note however not all members have pharmacy coverage through BCBSVT Refer to our ldquoContact Information for Providerrdquo sheet on our provider website under ldquoPharmacy Benefit Managerrdquo for a list of exclusions
Radiology prior approvals are reviewed by AIM Speciality Health
Special Notes Related to Prior Approval for Ambulance Services
Refer to the current prior approval listing to determine which ambulance service(s) require prior approval
We encourage the referring provider to obtain prior approval for ambulance services
Ambulance providers cannot contract with BCBSVT and therefore members are financially responsible for the services provided if prior approval is not obtained In addition the referring provider has the clinical information we need to make a decision
When a rendering provider is requesting a prior approval for ambulance services they need to know the ambulance service name location and national provider identifier No coding is necessary BCBSVT uses an ambulance transport service code
BCBSVT has two business days to review and make decisions on ambulance prior approval requests unless they are marked urgent Urgent requests have 48 hours to have a decision rendered If you have enough time to file for prior approval before the transport you should not mark the request as urgent
Special Notes Related to Prior ApprovalReferral Authorizationbull Home Health Agencies or Visiting Nurse Associations a new authorization or an updateextension of an existing authorization does not need to be
submitted or created should a member experience an inpatient admission during date spans for already approved services
If the inpatient stay results in the need to adjust the date span of already approved services or will result in services spanning a new calendar year you need to contact our integrated health team at (800) 922‑8778 We will adjust the existing authorization accordingly
Retrospective review of prior approvals and referral authorizationsPrior Approval and Referral Authorizations should always be secured prior to the service(s) being rendered Providers and facilities are held financially responsible if a prior approval is required and not obtained Providers are not able to file appeals for lack of prior approval However we will conduct retrospective review for medical necessity when one of the applicable circumstances listed below occurs and the service was rendered without obtaining prior approval as required Provider must contact BCBSVT within a reasonable time not to exceed 60 calendar days from the date of service unless documentation provided
Chiropractic Servicesbull Chiropractic services rendered within three (3) days of visit following visits 12th 18th 24th etc visits
Coverage Unknown Changed or Incorrectbull Provider not aware member had BCBSVT coveragebull Provider not aware member had a change in BCBSVT coveragebull Provider advised member was not active through eligibility verificationbull Provider received incorrect information about memberrsquos coverage (eligibility benefits or Medicare status)
40
Discharge Planningbull Discharge planning occurred during the Planrsquos non‑business operating hours
Durable Medical Equipment (DME) Continuationbull Continuation requests within 30 calendar days of the last covered day of the trial authorization for CPAPBiPAPTENS or any other continued DME
Genetic Testingbull Request received within 60 days of the specimen being collected and sent to the lab for processing
Misquotebull BCBSVTAIM or ESI quoted that a service procedure or supply did not require prior approval to a provider when it is on an applicable prior approval list
Treatment Plan Changebull Provider requests a new or different procedure or service when a change in treatment plan was necessary during a procedureservicebull Provider determines additional services that require prior approval are needed during a proceduresurgerybull Provider has an approved prior approval on file but determines the need for other or additional services during a procedure or a change in treatment
plan is requiredbull Provider received approval for a specific code(s) but when the procedure was rendered the code(s) changed by the National Coding Standards
Unable to reach BCBSVT andor delegated vendor partnersbull Provider attempted to obtain prior approval but was unable to reach BCBSVT due to extenuating circumstances (natural disaster power outage)
Requesting a Retrospective Review
If a provider identifies a service that qualifies for a retrospective review heshe must submit a prior approval form noting it is a retrospective review and includes documentation that
1 Supports the procedure provided and
2 Provides details of why prior approval was not originally requested
We notify the provider of the outcome of the retrospective review within 30 days from receipt of request unless additional information is requested from the provider or it is not eligible for review
Retrospective Reviews of Prior Approval MisquotesIf Provider contacts Customer Service and is erroneously informed that a service or procedure does not require prior approval or referral authorization (but the service or procedure is in fact listed on the applicable prior approval or referral authorization listing) Provider may request retrospective review for services or procedures billed in reliance on the Customer Service quote Provider must contact BCBSVT within a reasonable time (not to exceed sixty (60) calendar days) after receiving the first remittance advice showing that the claim for the procedure or service was denied for lack of prior approval or referral authorization BCBSVT will not consider requests for retrospective review for services or procedures if more than sixty (60) calendar days have passed since the Providerrsquos receipt of the first remittance advice showing a denial for lack of prior approval or referral authorization Quotes from Customer Service represent prior authorization or referral authorization requirements at the time of the quote and Providers must verify prior approval or referral authorization requirements regularly by reviewing the listings available on BCBSVTrsquos website
Pre-notification of AdmissionsUnder the Planrsquos certificates of coverage pre‑notification of scheduled inpatient admission is required Pre‑notification enables the Planrsquos Integrated Health staff to assess the medical necessity of the requested procedure and the appropriateness of the requested setting of care (inpatient versus outpatient) Clinical information pertinent to the request is collected as needed The information is reviewed in conjunction with nationally recognized health care guidelines andor other data sources identified earlier in the description
41
If the Integrated Health staff cannot certify the request the case is referred to a Plan medical director The Plan medical director may contact the attending physician or consult a specialist to address unresolved questions or to discuss other possible alternatives prior to issuing an adverse determination The medical director may approve or deny a service
Written notification of both approval and denial determinations are sent to the member and treating provider (if known) within 15 days of request Copies of the letter are sent to the treating providers facility and member The Planrsquos integrated health department also keeps a copy as part of the memberrsquos electronic record In the case of an adverse determination the appeal process is outlined in the letter and is also discussed later in this program description
Each case reviewed is evaluated for case andor disease management Both integrated health staff and physician reviewers participate in a team effort that focuses on the memberrsquos unique needs The appropriateness of services access to cost effectiveness and quality of services are all stressed
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Admission Review
All admissions that require review but occur without pre‑notification are considered urgent or emergent and are evaluated within 24 hours or one business day of notice to the Plan Admission reviews in this category are reviewed as noted above A clinician and medical director are available to providers (by toll free telephone number) 24 hours a day seven days a week to render utilization review determinations for urgent or emergent care Verbal notifications of all urgent and non‑urgent decisions are made within 24 hours to both the member and provider Written notifications are issued within 24 hours of verbal notification
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing course of treatment During inpatient hospitalization for circumstances requiring focused review the Planrsquos clinical reviewers monitor the care being delivered using Milliman Health Care Guidelines Current Edition andor locally approved health care guidelines Through telephonic review the Planrsquos clinician reviews the medical information provided by the facilityrsquos UR staff while the member is hospitalized Authorization of continued hospitalization is based on the medical appropriateness of the care being delivered and the memberrsquos unique needs The Plan uses the concurrent review process to facilitate discharge planning with the treatment team
If there is a length of stay or level of care issue it is discussed with the Planrsquos medical director and if necessary the attending physician and the hospital utilization review coordinators within 24 hours of obtaining the necessary medical information In the event of an adverse decision verbal notification is provided to the member and treating provider (if known) and a written notification is sent within 24 hours of the verbal notification to the member and the provider(s)
During the concurrent review process if the integrated health staff identifies a quality of care issue the case is referred to the QI department or the credentialing committee for investigation The BCBSVT QI department or credentialing committee will use the BCBSVT Quality Improvement Policy Quality of Care and Risk Investigations Policy to complete the investigation The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
The Plan does not retroactively deny reimbursement for services that received prior approvalpre‑notification except in cases of fraud including material misrepresentation See provider contracts for more complete details
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process During the concurrent review process the Planrsquos clinician case manager works collaboratively with the caregivers to facilitate appropriate and timely services The extent of the clinicianrsquos direct role in planning and arranging post‑discharge care varies with the patient needs and includes a collaborative approach with the hospital staff care team patientfamily and community resources representatives as appropriate Upon discharge each member is contacted by the discharge outreach coordinator a clinician who reviews the memberrsquos discharge plan and assists with coordination of services as needed During the outreach the clinician will assess the need for referral to case management disease management or behavioral health management and will facilitate said referral if applicable
42
Urgent Pre-Service Review
Urgent pre‑service review applies to any request in which the memberrsquos health could be compromised by delay Expedited decisions are reached and providers are notified within 72 hours of the request Verbal notification is provided to the member and treating provider (if known) with written confirmation of the decision within 24 hours of telephone notification
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management Society of Americarsquos case management definition Standards of Practice for Case Management revised 2010
ldquoCase management is a collaborative process of assessment planning facilitation and advocacy for options and services to meet an individualrsquos health needs through communication and available resources to promote quality cost‑effective outcomesrdquo
The specialty case management program is a member‑centered proactive program designed to identify at‑risk members as early as possible The program works collaboratively with our disease management behavioral health dental and pharmacy partners and is focused on chronic diseases that are typically high‑cost and are potentially actionable with appropriate intervention and lifestyle changes The clinical case manager applies the four primary functions of case management advocacy assessment planning and facilitation to identify barriers to the member attaining appropriate timely and quality care The program is an organized effort to identify potentially high costhigh risk members with complex health needs as early as possible assess alternative treatment options assist in stabilizing or improving memberrsquos health care outcomes and manage health care benefits in the most cost effective manner The managed diagnostic categories and focus populations include diabetes general HIVAIDS acute and chronic neurology progressive degenerative disorders end of lifepalliative care high‑risk obstetrics pediatrics transplant and oncology with or without metastasis
The Plan annually assesses the characteristics and needs of its member population and relevant subpopulations and reviews and ldquoif necessaryrdquo updates the case management process and case management resources to address member needs
If it is determined that the member has the potential to benefit from case management a welcome packet is sent defining case managementrsquos role and the memberrsquos rights and responsibilities in participation Once the member consents to participate in and collaborate with the case manager a comprehensive assessment is completed with the member who is considered to be an active participant on the interdisciplinary team and the health care team In collaboration with the member case manager and provider a member‑specific case management plan of care is developed to support the memberrsquos clinical plan of care which includes both short and long term prioritized goals nursing interventions a member self‑management plan and discharge criteria
Case management services may be terminated once the goals are met and the member no longer requires case management services or since the program is voluntary the member requests termination of services Case management services can be reinstated at any time All information regarding the member is considered confidential and is not shared with anyone who is not part of the interdisciplinary team without written consent of the member or person with medical power of attorney
Episodic Case ManagementAuthorization of Services
Episodic case managementauthorization of services targets individuals who have short‑term intervention needs usually for a period of six to 12 weeks or for a specific illness episode This applies also for members who demonstrate evidence that their needs are being met by support groups or other community agencies and whose only needs are to have services authorized The value of this program is to expedite care from hospital to home or an alternative setting and to promote continuity of service across the continuum
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVTTVHP members directly into our case or disease management programs by calling (800) 922‑8778 option 3 Our intake triage staff will record the information and complete outreach to the member for enrollment
Rare Condition Program (BCBSVT partnership with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve their conditions enhance their knowledge and self‑management skills and achieve your therapeutic goals for them Full details are available in our online brochure located on the provider website under Provider ManualReference GuidesGeneralAccordant
43
Section 5Quality Improvement (QI) ProgramBlue Cross and Blue Shield of Vermont and The Vermont Health Planrsquos Quality Improvement Program provides the framework by which the organizations assess and improve the quality of clinical care and the quality of service provided to our members Both organizations are referred to here as ldquothe Planrdquo To receive a copy of the Planrsquos Quality Improvement Program Description contact the Director of Quality Improvement at (802) 371‑3230
The Plan QI program identifies the leading health issues for our members areas where current treatment practice runs counter to established clinical guidelines and by working with both members and providers takes action to modify or improve current treatment practice In addition the program assesses the level of service the Plan and our networks provide to our members and by working with members and providers takes action to improve service Input from both providers and members is essential to meeting the goals of our program
Some of the Planrsquos quality improvement initiatives that affect providers are outlined below The Plan reserves the right to develop and implement other quality improvement initiatives that may require provider involvement or cooperation
Quality Improvement Projects As part of their participation in managed care products the Plan expects its provider network to contribute to the success of the Planrsquos quality improvement projects The projects define a measurable goal around a specific clinical issue in a particular population identify barriers that contribute to gaps in care implement member and provider interventions to address the issue measure the success of the project and then reassess barriers and interventions Through FinePoints a newsletter to the provider community and other notifications the Plan alerts its provider network to its quality improvement projects and the role of providers The Plan expects providers to participate in the quality improvement project encourages members to participate and provides feedback on the project
Quality Profiles Each year the Plan compares practice patterns in Vermont to nationally recognized guidelines The results are reported to physicians so they may evaluate their practice patterns in relation to national guidelines and their peers In cases where practice patterns seem inconsistent with national guidelines and the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Clinical Guidelines The Plan develops or adopts clinical guidelines that are relevant to its clinical quality improvement goals The Plan reviews and as appropriate updates its clinical guidelines a minimum of every two years and distributes the guidelines to providers within the relevant practice area
Medical Record Reviews amp Treatment Record Reviews The BCBSVT Quality Improvement Policy Medical Record Review amp Treatment Record Review provides the complete details of the definitions review procedure performance improvement plans and reporting The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider consultant for a paper copy
Member Satisfaction Surveys The Plan surveys members who have sought services from primary care or OB‑GYN physicians to assess their satisfaction with these network physicians Periodically the Plan shares results of member satisfaction surveys with physicians In cases where member satisfaction is not consistent with the Planrsquos standards the Plan takes appropriate action to correct deficiencies monitors provider performance against corrective actions and takes appropriate and significant action when a provider does not follow through on corrective action
Member Complaints The Plan documents and tracks member complaints and may as appropriate share results with network providers In circumstances where member complaints focus attention on a specific concern about a provider the Plan may share the feedback with the provider engage the provider in developing corrective action monitor the providerrsquos performance against corrective action and take appropriate and significant action when a provider does not follow through on corrective action
HEDIS and Quality Data Gathering On an annual basis the Plan participates in the HEDIS (Health Plan Employer Data and Information Set) survey and at the same time gathers data to support its quality improvement projects HEDIS is the most widely used set of performance measures in the managed care industry and provides important information about how the Plan compares to other plans in terms of quality indicators The Planrsquos
44
participation is required by the State of Vermont and is critical to the improvement of the clinical quality for its members
Standards of Care Each year the Plan develops or adopts standards of care relevant to the health needs of the Planrsquos membership The Plan distributes guidelines to its networks and measures guideline compliance The Plan updates the guidelines at least every two years The Plan has adopted clinical practice guidelines in the following areas asthma hypertension diabetes smoking cessation obesity obstructive sleep apnea depression preventive health adult migraine headaches anti‑depressant medication follow‑up colonoscopy and acute pharyngitis
Provider Feedback Developing and maintaining a preferred partner relationship with the provider community is one of our goals as a company and a focus of our quality improvement program There are many ways that providers can let us know how wersquore doing
bull Contact a provider relations representative at (888) 449‑0443bull Provider complaintsmdashcall our Customer Service department at (800) 924‑3494 The Plan logs and reports on complaints regularly to note trends and
areas of particular concernbull Provider Satisfaction Surveysmdashconducted annually and mailed to every provider in our network Look for yours every fallbull Participation in quality improvement committees is outlined below
Quality Improvement Committees
The Plan maintains several quality improvement committees that provide an opportunity for network physicians to participate actively in developing and overseeing the Planrsquos quality improvement program The Plan invites providers to contact the quality improvement department at (802) 371‑3230 if they would like to participate in a quality committee
Quality Oversight Committee This committee provides oversight of the quality improvement program It reviews HEDIS and CAHPS data and other quality indicators identifies and prioritizes quality improvement opportunities develops and oversees quality improvement projects and other quality activities and serves as liaison for the Planrsquos quality program and the provider network The committee meets six times a year
Quality Improvement Project Teams Through quality improvement projects the Plan seeks to improve the care and service its members receive both from the Plan and its networks The projects are carried out through the work of a team made up of clinical and non‑clinical staff The Plan invites its network providers to propose quality improvement projects or to serve as clinical advisors on quality projects
Credentialing Committee The Planrsquos credentialing committee reviews the qualifications and background of providers applying or reapplying for networks participating with the Plan In addition the Planrsquos credentialing committee reviews quality issues that may arise with a particular provider and makes appropriate recommendations
Specialty Advisory Committee (SAC) The Plan convenes Specialty Advisory Committees as necessary to review clinical guidelines on particular topics and assists in tailoring the guidelines for more effective use in Vermont Examples of past SAC topics include cardiology orthopedics oncology and OB‑GYN The Plan encourages network providers to propose SAC topics or to volunteer for a SAC
BCBSVTTVHP Special Health Programs
Better Beginnings
Better Beginningsreg is a voluntary and comprehensive prenatal program The program identifies early in their pregnancies those women who may be at risk for pregnancy complications It encourages early prenatal care and collaboration between the member and her provider to reduce complications and the potential for associated high costs Better Beginnings provides benefits tailored to individual needs that may help to reduce risk factors that can trigger pre‑term labor andor other complications All BCBSVT members are eligible for the program with the exception of the Federal Employee and New England Health Plan programs
An expectant mother can enroll at any time during her pregnancy but BCBSVT must receive enrollment paperwork prior to delivery Ideally a member will enroll as early as possible in her pregnancy There is a reduction in benefits if a member enrolls after 34 weeks gestation Please refer the expectant mother to the website wwwbcbsvtcommemberHealth_and_Wellnessbetterbeginningshtml on information on how to register
45
Upon receipt of the completed paperwork a BCBSVT registered nurse case manager will contact the expectant mother to inquire about the progress of her pregnancy and to discuss any possible risks the HRA revealed We send educational materials on pregnancy and childbirth to the expectant mother The same RN case manager will follow the member through her pregnancy and in the postpartum period The nurse may offer case management if the expectant mother is at high risk for complications
If you would like more information on the Better Beginningsreg Program or would like to refer a patient please call (800) 922‑8778 select option 1 Members may also call our Customer Service department at (800) 247‑2583 for more information about the Better Beginningsreg Program
Brochures for this program are available free of charge These brochures can be placed in your waiting areas or you may include them in patient care kits To order a supply simply contact your provider relations representative at (888) 449‑0443 and request Better Beginningsreg Program brochures
Diabetes EducationTraining
BCBSVTTVHP provides a benefit for outpatient diabetes self‑management educationtraining services and related durable medical equipment and supplies for eligible members This benefit is provided so that our diabetic members can learn strategies to effectively manage their diabetes and to avoid complications often associated with this chronic disease
Providers of outpatient diabetes educationaltraining services must participate with the Plan and meet the Planrsquos credentialing criteria for diabetes education in order to be eligible for reimbursement Eligible providers must submit a separate credentialing application specific to diabetes education to BCBSVTTVHP The credentialing procedures are similar to those outlined in section one but the Plan also requests information on providersrsquo certification and training in the education and management of diabetes
Benefits are available for diabetes self‑management eductiontraining services for eligible members if all of the following criteria is metbull The member has one of the following diagnosis
bull Insulin dependent diabetesbull Gestational diabetesbull Non‑insulin dependent diabetes
bull The member is capable of self‑management including self‑administration of insulin (or in the case of children parental management)bull A qualified outpatient diabetes educationtraining education program that participates with the Plan
Hospice
The hospice program offers eligible patients who are terminally ill and their families an alternative to hospital confinement The attending physician in collaboration with a participating home health agency prepares a comprehensive home care treatment plan in order to assure the memberrsquos comfort and relief from pain
Benefits We cover the following services by a Hospice Provider and included in the bill
bull skilled nursing visitsbull home health aide services for personal care services bull homemaker services for house cleaning cooking etcbull continuous care in the homebull respite care servicesbull social work visits before the patientrsquos deathbull bereavement visits and counseling for family members up to one year following the patientrsquos deathbull and other Medically Necessary services
Requirements We provide benefits only if
bull the patient and the Provider consent to the Hospice care plan and a primary caregiver (family member or friend) will be in the home
46
BlueHealth Solutions
The Blue HealthSolutions information and support program helps our members learn about the care theyrsquore getting The various components of the program (a 24‑hour phone‑in nursing support line an advertising‑free website and a self‑help book among them) help our members to learn about all the options available
If a member has a chronic or serious condition they can get phone support information by mail and videotapes on a range of diagnoses and treatment options from our clinicians If a member needs answers to everyday problems our clinicians provide easy access at any time of the day or night by phone or via the web Members can call toll‑free (866) 612‑0285 to speak with one of our clinicians
In addition to health management and support programs BCBSVT has a host of fun effective programs designed to reward our members for healthy behavior Among them
bull WalkingWorks a program that makes it easy and fun to keep track of the success at walking for fitnessbull BlueExtras a program that provides discounts on weight loss programs hearing aids and a host of local goods and servicesbull EatSmart Vermont a program that encourages restaurants to offer and promote healthy choices on their menus
At BCBSVT our goal is to ensure that all our members get the care and support they need regardless of their health care status Our full spectrum of Blue HealthSolutions programs allows us to maximize each memberrsquos chance at getting and staying healthier By using Blue HealthSolutions our members make the best use of the dollars they spend on health benefits
Provider Selection StandardsTo participate in the BCBSVT or TVHPrsquos networks a provider must
1 Be licensed in a discipline that has consistent requirements and training programs (the Plan specifically excludes certain licensed providers including but not limited to professional nurse midwives massage therapists and acupuncturists)
2 Meet initial credentialing criteria as outlined in the Initial Credentialing Policies available upon request from your provider relations consultant
3 Agree to a recredentialing review every three years as outlined in the Recredentialing Policies
4 Provide a complete application including an attestation ofbull Ability to perform the essential functions of the positionbull Lack of illegal drug use at presentbull History of loss of license andor felony convictionsbull History of loss or limitation of privileges or disciplinary actionbull Accuracy and completeness of information
5 Agree to the Planrsquos access and appointment availability standards as specified in Vermont Rule 10
6 Agree to provide 24‑hour coverage (primary care providers only)
7 Practice in the state of Vermont or in a state with a contiguous border with Vermont (except Durable Medical Equipment suppliers or Lab Services)
8 Agree to BCBSVT andor TVHP payment rates
9 Agree to sign a contract with BCBSVT andor TVHP and adhere to the contractual provisions
Provider Appeal Rights
The Plan may deny a providerrsquos participation in its networks for reasons related to credentialing criteria quality or performance Physicians or providers who are notified of a denial are entitled to a statement of the reasons for the denial A provider wishing to appeal a removal from the network or entry into the network may be entitled to a hearing as outlined in the policy entitled Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network available upon request from your provider relations representative
47
Credentialing verification is required for all lines of business to review the background and performance of physiciansproviders and to determine their eligibility to participate in the network Credentials such as current license license history specialty Drug Enforcement Agency (DEA) Certificate malpractice history and education are verified when a provider enters into the network and again every three years
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan delegates a portion of its network credentialing to Physician Hospital Organizations (PHOs) The Plan monitors these delegatesrsquo credentialing procedures and assures compliance with Plan standards as well as the standards of the National Committee for Quality Assurance (NCQA) and the Department of Financial Regulation (DOFR)
Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network
The BCBSVT Quality Improvement Policy Provider Appeals from Adverse Contract Action and Denials of Participation in BCBSVT network is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider consultant for a paper copy
Recredentialing Procedures
The Plan recredentials all network providers and facilities every three years Providers and facilities must return a completed recredentialing application The Plan will conduct primary source verification and a performance appraisal for the credentialing committeersquos review Performance appraisal elements include
bull Member complaintsbull Member satisfaction surveysbull Quality Improvement profilesbull Quality reviews (site visits and medical record reviews)bull Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in a lockedsecured area All Plan employees sign a confidentiality statement as a condition of employment All materials and processes are subject to the standards outlined in the Planrsquos Confidentiality and Security Policy available upon request All credentialing information shall be retained for a minimum of two credentialing cycles or for six years whichever is longer
The minutes and records of the credentialing committee are confidential and privileged under 26 VSA sect1443 except as otherwise provided in 18 VSA sect1914(f)(2) and Vermont Rule 10306(B)
Providers may request a copy of the Planrsquos Credentialing Policy from our Provider Relations Department by calling (888) 449‑0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a manner that is current detailed and organized permitting effective member care and quality review Records may be written or electronic The Plan conducts a medical record review of its high‑volume primary care providers and a treatment record review of its high‑volume mental health and substance abuse providers at least every three years we check for critical elements general elements and confidentiality and organized record keeping policies The Plan does not include Blueprint practices using electronic records as the state deems them compliant with this requirement
To pass the review provider records must reflect 100 percent compliance with critical elements confidentiality organized record keeping policies and 80 percent compliance with the general elements The Plan reserves the right to extend this records review to any provider of any specialty at any time and apply the same standards The Plan requires performance improvement plans from providers who do not pass the medical record review or treatment record review and conducts a repeat review in approximately six monthsrsquo time The Plan will maintain all results and correspondence relating to record review in the secure credentialing database The Plan may use these results to make future credentialing decisions
The complete Medical Record Review amp Treatment Record Review policy is available on our secure website We would encourage you to review for the full details If you encounter any issues or are unable to access the web please contact your provider relations consultant at (888)449‑0443
48
Retrieval and Retention of Member Medical Recordsbull Members must have access to their medical records during business hours for a charge not to exceed copying costsbull The Plan will have access to member medical records during regular business hours to conduct quality improvement activitiesbull Providers retain records as per individual practice policies in accordance with all state and federal laws
Office Site Review
The BCBSVT Quality Improvement Policy Site Visit and Medical Record Keeping Policy provides the complete details of the requirements The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies Quality Improvement Or you can call your provider relations consultant for a paper copy
49
Section 6NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to December 31 2018 For information related to claims with a date of service January 1 2019 or after please refer to our on-line provider handbook
For BlueCard Claims this information is only valid for claims with a date of service on or prior to November 16 2017
For FEP claims this information is only valid for claims with a date of service on or prior to March 8 2018
General Claim InformationOur mission is to process claims promptly and accurately We generally issue reimbursements on claims within 30 calendar days
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA transaction set or on paper using the standard CMS 1500 claim form
Services must be reported using the industry standard coding of Current Procedural Terminology (CPT) and or Health Care Procedure Coding Systems (HCPCS) To align with the industry on a quarterly basis (January April July and October) BCBSVT also updates the CPT and HCPCS codes We complete a review of the newreviseddeleted codes and post a notice to the news area of our provider website at wwwbcbsvtcom advising of any changes in prior approval requirements changes in unit designation and any other information you should be aware of specific to the newreviseddeleted codes The posting appears no later than two weeks prior to the effective date
Diagnosis must be reported using Internal Classification of Disease 10th revision Clinical Modification (ICD‑10‑CM) ICD‑10 diagnosis codes are to be used and reported at their highest number of characters available The Plan begins to use the newest release of ICD‑10‑CM in October of each year Please note BCBSVT does not allow manifestation codes to be reported in the primary diagnosis field
Balance Billing Reminders
Covered ServicesmdashParticipating and network providers accept the fees specified in their contracts with BCBSVT and TVHP as payment in full for covered services Providers will not bill members except for applicable co‑payments coinsurance or deductibles
Non-Covered Servicesmdash In certain circumstances a provider may bill the member for non‑covered services Please refer to Section 1 ndash Billing of Members and Non‑Covered Services for details
ReimbursementmdashPayments for BCBSVT and TVHP are limited to the amount specified in the providerrsquos contract with BCBSVT andor TVHP less any co‑payments coinsurance or deductibles in accordance with the memberrsquos benefit program
Claim Filing Limits
New ClaimsmdashNew Claims must be submitted no more than one hundred eighty (180) days from the date of service or in the case of a coordination of benefit situation one hundred eighty (180) days from the date of the primary carrierrsquos payment Claims submitted after the expiration of the one hundred eighty (180) day period will be denied for timely filing and cannot be billed or collected from the Member A Provider may request a review of denials based on untimely filing by contacting our Customer Service Department or submitting a Provider Inquiry Form within ninety (90) days of the Remittance Advice denial The Provider Inquiry Form must include supporting documentation such as original claim number copy of an EDI vendor report indicating that the claim was accepted for processing by BCBSVT within the filing limit or a copy of the computerized printout of the patient account ledger with the submission date circled Requests for review of untimely filing denials will be reviewed on a case‑by‑case basis If the denial is upheld a letter will be generated advising the provider of the outcome If the denial is reversed the claim will be processed for consideration on a future Remittance Advice
AdjustmentsmdashMust be submitted no more than one hundred eight (180) days from the date of BCBSVT or TVHP original payment or denial
50
Claim submission when contracting with more than one Blue Plan Providers who render services in contiguous counties or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have created three guides to assist these providers the guides are located on our provider website at wwwbcbsvtcom
Use of Third Party BillersVendors
BCBSVT refers to third‑party billers (or vendors) as those entitiespersons who are not physically located at a providergroup office are not direct employees of the providergroup and are submitting claims or following up on accounts on behalf of the providergroup and have a business associate relationship with the billervendor The providergroup must authorize third‑party billers (or vendors) with BCBSVT in order for information to be released Below are the two methods by which third‑party billers (or vendors) would access providergroup information and the steps the providergroup needs to take to grant access
bull For electronic access through the provider resource center the providergroups local administrator will need to grant access to the third‑party biller (or vendor) Note third‑party billers (or vendors) cannot be a local administrator for a providergroup Full details are available in our online provider resource center manual
bull In order for a third‑party biller (or vendor) to receive written correspondence from BCBSVT (such as ntoices letters or e‑mails) or to obtain information via phone from our customer service team the providergroup must submit written verification of (1) the name of the billervendor (2) the names of the billervendor staff who will be calling and (3) the phone number the billervendor will be calling from These notifications must be sent to your provider relations consultant via e‑mail fax or US Postal service You will receive a confirmation once the set‑up is complete and the third‑party biller (or vendor) has access
The providergroup should be prepared to produce proof of a business associate relationship with the billervendor upon request
If you change your third‑party biller (or vendor) you must notify your provider relations consultant immediately so access can be revoked
Once a providergroup office has notified BCBSVT that the providergroup office uses a third‑party biller (or vendor) the providergroup office must be prepared to disclose the identity of that third‑party biller (or vendor) to BCBSVTs customer service staff upon request if the providergroup office calls directly regarding that status of a claim
Grace Period for Individuals through the Exchange
Individual members enrolled through the Statersquos Health Exchange have very specific grace periods
The federal Affordable Care Act requires that individuals receiving an advanced premium tax credit for the purchase of their health insurance be granted a three‑month grace period for non‑payment of premium before their membership is terminated
BCBSVT administers the grace period as follows
Claims for dates of service during the first month of grace period
We process the claims make applicable payments and reports through to a remittance advice These payments are never recovered even if the membership terminates at the end of the grace period If you find at a later date (and within 180 days of original processing) that you need to request an adjustment on one of these claims simply submit following our standard guidelines and the adjustment will process through as usual If additional money is due it will be paid
51
Claims for dates of service during the second and third month of the grace period Claims are suspended We alert you that the claim is suspended by letter sent through the US Postal Service to the address you have on file as a payment address
bull If the premium is paid in full at any point during month two or three the claim(s) is released for processing and reported through to a remittance advice paying any applicable amounts
bull If the premium is not paid in full prior to the end of the three‑month grace period the suspended claim(s) is denied through to a remittance advice and reports as ldquomembership not on filerdquo reflecting the full billed amount as the memberrsquos liability The member also receives a Summary of Health Plan with this information
bull Per the Affordable Care Act when a member is within a grace period they must pay all amounts due up through their current billing period to keep their insurance active
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising the member is within their grace periods and the correct claim or adjustment can be submitted after payment is made or termination is complete
Take Back of Claim Payments amp Overpayment Adjustment Procedures
It is BCBSVTrsquos and TVHPrsquos policy to collect any overpayments made to the provider in error
When membership is terminated retroactively BCBSVT and TVHP recover payments made for services provided after the termination date Providers should then bill the member directly Individuals who are covered through the Exchange have separate guidelines For full details see ldquoGrace Period for Individuals Through the Exchangerdquo
If we learn of other insurance or other party liability BCBSVT and TVHP recover payments made for services
BCBSVT partners with Cotiviti Healthcare to provide reviews on coordination of benefit (COB) claims
Cotiviti Healthcare looks at the following COB conceptsbull ActiveInactivebull Automatic Newborn Coveragebull Birthday Rulebull DependentNon dependentbull Divorce Decreebull LongerShorterbull Medicare Age Entitlement Disability Entitlement Crossover Domestic Partner ESRD Entitlement Home Health Part B only
Cotiviti also performs claim reviews for (1) duplicate services (2) claims suspected to have administrative billing and payment errors (3) BCBSVT observation services payment policy and (4) BCBSVT provider based billing payment policy
Most of the reviews are performed without requiring any additional information from providers They rely on the information contained on the claim(s) attachment(s) or information BCBSVT has already collected during the initial COB process
Cotiviti Healthcare may need to outreach to your office directly to obtain more information Please be advised that we do have a signed business associate agreement with Cotiviti Healthcare You can release the requested information to them directly Please make sure you do respond within the timeframe that is specified in the Cotiviti Healthcare request
Change Healthcare (formerly known as EquiClaim) performs quality assurance review of claim processing forbull Facility billing (including DRG reimbursements)bull High cost injectable drugsbull Home infusionbull Renal dialysis
52
If you receive a request for information from Change Healthcare (or EquiClaim as they still use that name at times) please make sure to respond promptly
When you detect an overpayment please do not refund the overpayments to BCBSVTTVHP or the patient Instead please complete a Provider Overpayment form For an accurate adjustment it is important to include all the information requested on the form We will adjust the incorrectly processed claim by deducting from future payments
We prefer to recover rather than accept funds from you becausebull Claims history will simultaneously be corrected to accurately reflect the service and paymentbull The remittance advice will reflect correction of the original claim andbull Providers do not incur the expense of sending a check
The Provider Overpayment form is available on the wwwbcbsvtcom provider website
BCBSVT also has a partnership with CDR Associates for credit balance reviews CDR performs on site retrospective provider credit balance reviews of all active BCBSVT accounts
Focus on the CDR review
bull Duplicative and multiple payments
bull Coordination of benefitsother liable insurance
bull Payment in excess of contractual requirements
bull Credit adjustment to charges
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim the amount of the incorrect payment is automatically deducted from future payments to the provider
The overpayment adjustment will report as a negative on the providerrsquos Remittance Advice The amount due will be subtracted from the total payment for the Remit When the amount of the overpayment adjustment is larger than the total amount due or when the overpayment adjustment is the only line item on the Remittance Advice a negative balance is created The negative balance will report through to every Remit until the balance is cleared up
Do not issue checks to the Plan for the amount the report shows as a negative Typically negative balances are resolved with the next Remit and refunding the money would only result in a provider overpayment
Please note Negative balances do not cross product lines For example if you have a negative balance on a BlueCard remittance advice the outstanding negative balance would not be taken on your indemnity TVHP or FEP remits It would continue to be taken on your next BlueCard remittance advice
Interest Payments
For qualifying claims interest payments are based upon the amount paid by BCBSVT
Where to Find Co-payment Information
A co‑payment is an amount that must be paid by the member for certain covered services This amount is charged when services are rendered The amount of co‑payment can be obtained by
bull Checking the front of the memberrsquos identification cardbull Using the secure website at wwwbcbsvtcom (see Section Two of this manual for details) orbull PCPs can refer to the monthly membership reports
53
Co-payments and Health Care Debit Cards
Some members to cover out‑of‑pocket costs use healthcare debit cards Out‑of‑pocket expenses are co‑payments deductibles andor coinsurance amounts that are not paid by the memberrsquos health plan Debit cards typically have a major debit card logo such as MasterCardreg or Visareg
Some BlueCard members have a Blue Cross andor Blue Shield health care debit card ndash a card with the nationally recognized Blue Cross andor Blue Shield logos along with the logo from a major debit card
The debit card should only be used to collect co‑payments or to pay outstanding balances on billing statements (after BCBSVT has processed the claim)
If a member arrives for an appointment and presents a debit card you may charge the co‑payment amount to the debit card Please be sure to verify the co‑payment amount before processing payment The card should not be used to process the full charges up front
Submit the memberrsquos claim to BCBSVT
Your Remittance Advice will provide you with the results of claims processing and reflect any balances due from the member The member may choose to pay any balances due with the debit card In that case the member would bring the card to your office and authorize the payment
How to Use a Health Care Debit Card
The cards include a magnetic strip so if your office currently accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos payment
Select ldquocreditrdquo when running the card through for payment No PIN is required
The funds will be sent to you and will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a co‑payment (or deductible) from a member or where the provider wishes to collect a lesser amount than that which is due under the terms of a memberrsquos benefit program The circumstances under which a provider may waive all or a portion of a co‑payment or deductible due from a member are limited however A provider may not waive a memberrsquos co‑payment or deductible in an attempt to advertise or attract a member to that providerrsquos practice A provider should limit waiver of co‑payments or deductible to situations where (1) the provider has a patient financial hardship policy (sometimes called a sliding‑scale) and (2) the member in question meets the criteria for reduced or waived payment
When to Collect a Co-payment
High Dollar Imaging
When a member has a co‑payment for high dollar imaging the co‑payment amount is only taken on the facility claim The professional (reading) claim will not apply a co‑payment
For plans with a co‑payment and then a deductible the facility claim will take the co‑payment and any applicable deductible The professional (reading) claim will take only the applicable deductible
Please note Administrative Services Only (ASO) groups may have different applications of co-payments for high dollar imaging
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance abuse services for the same co‑payment as their primary care provider visit A list of these services are available on our provider website at wwwbcbsvtcom under policies provider manual amp reference guides mental health and substance abuse co‑payment
54
Physicianrsquos Office
A co‑payment is collected when an office visit service is rendered Generally co‑payments are applied to the Evaluation and Management (E amp M) services which include office visits and exams performed in the physicianrsquos office BCBSVT and TVHPrsquos reimbursement excludes the co‑payment that the physician collects from the member
If a member has two BCBSVT policies the member is responsible for one co‑payment the policy with the lowest co‑payment for the service will apply the co‑payment For example if the primary BCBSVT policy has an office visit co‑payment for $20 and the secondary BCBSVT policy has an office visit co‑payment of $10 the member will only be responsible for a $10 co‑payment
Preventive Care
BCBSVTTVHP members have preventive benefits that either follow the federal guidelines of the Affordable Care Act (ACA) or are part of their ldquograndfatheredrdquo employer benefit and do not take a co‑payment
Grandfathered preventive care follows the traditional BCBSVT preventive guidelines
Groups with the federal preventive benefit also include benefits for womenrsquos health services with no additional co‑payment We have posted a brochure for the federal preventive benefits to the References area of our provider website This brochure provides the details on the qualifying Current Procedural Terminology or Health Care Procedure Coding System and diagnosis codes
To determine a member has a ldquograndfatheredrdquo employer benefit or a federal benefit verify a memberrsquos eligibility by logging into our secure provider website eligibility tool at wwwbcbsvtcom or call our customer service department at (800) 924‑3494 Business hours are Monday through Friday 7 am ‑ 6 pm
When verifying the member eligibility through the secure provider portal scroll down to the bottom of the section ldquoBenefit Plan Informationrdquo Click on the ldquoADDITIONAL RIDERSrdquo link
If one of the following riders appears after clicking on the link the preventive benefits are grandfatheredbull Grandfathered Benefits Riderbull 2010 Benefit Changes Rider ‑ GFbull Direct Pay 2010 Benefit Changes Rider ‑ GF
If a rider appears titled Preventive Care Rider the preventive benefit follows the federal benefit and includes womenrsquos health services
Member Responsibility for Co-payment
Members are expected to pay co‑payments at the time service is provided
Electronic Data Interchange (EDI) Claims
Submitting claims via EDI has many advantagesbull Reduced paperworkbull Savings on postage costsbull Immediate feedback on potential claim problems that affect paymentbull Reduced processing time
55
We encourage providers to submit claims electronically Electronic Billing Specifications are available on the bcbsvtcom website or if you have questions about electronic claims please call Electronic Data Interchange (EDI) support at (800) 334‑3441 option 2 or e‑mail us at editechsupportbcbsvtcom
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims All transactions received need to be in an 837 HIPAA compliant format To obtain a listing of clearinghouses please contact EDI Technical Support at (800) 334‑3441 option 2
Paper Claim Submission
Claims not submitted electronically must be submitted on an CMS 1500 claim form
How to Avoid Paper Claim Processing Delays
Please avoid the following to promote faster claim processingbull Missing or invalid informationbull Hand written claim formsbull Claim forms that are too light or too darkbull Poor alignment of data on the formbull Forms printed in non‑black ink
Attachments
Attachments typically slow down the claim payment process and most are not needed for claim processing Do not attach the following information to a paper claim
bull Medical documentation unless instructed to do sobull Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claimsbull Coordination of benefits (COB) information (primary carrier explanation of benefits)
bull Note BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull Descriptions for the following codes NEC (not elsewhere classified) NOS (not otherwise specified) along with applicable andor operative notesbull Modifiers requiring documentation (such as modifier 22 refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services first when a patient is covered by more than one health care plan
The primary health care plan is responsible for paying the benefit amount allowed by the memberrsquos contract
The secondary insurer is responsible for paying any part of the benefit not covered by the primary plan (as long as the benefit is covered by the secondary plan)
In most cases the total paid by both plans may provide payment up to but not exceeding BCBSVT and TVHPrsquos allowed price For BlueCard claims refer to Section 7
56
If COB applies the primary carrierrsquos Explanation of Benefits (EOB) must be attached to the claim and the following areas of the CMS 1500 must be completed
bull Box 9 Other insuredrsquos namebull Box 9a‑d Other insuredrsquos policy or group numberbull Box 11d Marked ldquoyesrdquomdashunless Medicare or Medicaid is the primary insurer then mark the ldquonordquobull Box 29 Amount paid
Note For BCBSVT members injuries which are work related are an exclusion of our certificates BCBSVT does not coordinate with workers compensation carriers or consider balances after workers compensation makes payment We do however allow consideration of services where workerrsquos compensation has denied the claim as not work related
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement (COBA) Program with the Centers for Medicare and Medicaid Services (CMS) This means that the majority of paper submissions for these types of claims are not required
At this time claims for Federal Employees (those with an alpha prefix of ldquoRrdquo) and claims that qualify as ldquomass adjustmentsrdquo do not crossover This means that Medicare cross over claims that are for FEP members or mass adjustments will have to be submitted by the provider or billing service after Medicare has processed the claim The original claim and a copy of the Explanation of Medicare Benefits (EOMB) will have to be submitted on paper to BCBSVT
How COBA works In order for crossover to occur BCBSVT provides the Medicare Intermediary with a membership file so that the intermediary can recognize BCBSVT as a secondary or supplemental insurer for the member The actual crossover occurs when the intermediary has matched a claim with a BCBSVT member Once the claim is matched to the BCBSVT membership file the intermediary forwards that claim to BCBSVT and sends an explanation of payment to the provider The explanation of payment will indicate that the claim has been forwarded to a supplemental insurer Once BCBSVT receives the claim it will process the claim according to the memberrsquos benefits and the provider contract and generate a remittance advice to the provider If the Medicare Intermediary is unable to match a memberrsquos claim to a supplemental insurerrsquos membership file the explanation of payment forwarded to the provider will indicate that the claim has not been forwarded a supplemental insurer In this case the provider should submit the claim on paper to BCBSVT and include the Explanation of Medicare Benefits (EOMB)
Quick Tipsbull When Medicare is primary submit claims to your local Medicare Intermediary After receipt of the explanation of payment from Medicare review the
indicatorsbull If the indicator on the RA shows the claim was crossed‑over Medicare has submitted the claim to BCBSVT and the claim is in progress
bull If there is no crossover indicator on the explanation of benefits submit the claim to BCBSVT with Medicarersquos EOMBbull If you have any questions regarding the crossover indicator contact the Medicare Intermediary directlybull Please note that all paper claims are reviewed and if the Medicare EOMB has not exceeded the 30‑day mark the complete claim will be returned
requesting that it be resubmitted at the 30‑day markbull Do not submit Medicare‑related claims to BCBSVT before receiving an RA from Medicare The one exception is statutorily excluded services or
providers Those can be submitted directly to BCBSVT using the modifier ldquoGYrdquo For full details see the modifier section belowbull Do not send duplicate claims Check claim status on the BCBSVT secure provider site or by calling Customer Service before submitting a Medicare
secondary or supplemental claim If you are not checking the status wait at least 30 days from the date of Medicare processing before resubmitting the claim
bull BCBSVT does not accept the CMS accelerated or advanced payment reports When it is necessary to submit a claim to BCBSVT for processing after Medicare the Medicare Explanation of Benefits must be provided
bull If CMS processed the claim as a mass adjustment the paper claim must be submitted as a corrected claim If it is not submitted as a corrected claim it will deny as a duplicate against the originalfirst claim submission
57
Special Billing Instructions for Rural Health Center or Federally Qualified Health Center
In most cases you should not have to submit Medicare secondarysupplemental claims directly to BCBSVT as they cross over directly to BCBSVT from CMS Federal Employee Program (FEP) claims do not cross over at this time and require paper submission
If you do have a need to submit a Medicare secondarysupplemental claim to BCBSVT submit it on paper in the format you submitted to Medicare (CMS 1500 or UB 04) and attach the Explanation of Medicare Benefits (EOMB)
Claim (s) crossed over from Medicare that have a manifestation ICD-10-CM codes as a primary diagnosis
Claims received by BCBSVT directly from Medicare reporting a primary diagnosis that is a manifestation code will be returned or denied to the billing vendor The BCBSVT system does not allow primary diagnosis that are manifestation code
Once the claim is deniedreturned to you you will need to update the claim form to report the primary diagnosis note at the top of the claim that it is a corrected claim attached the Medicare explanation of benefits and submit to BCBSVT for processing
CMS 1500 Claim Form Instructions
Go to wwwbcbsvtcomexportsitesBCBSVTproviderresourcesformsPDFsCMS-1500 instructionspdf for a link to complete instructions
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims attach a copy of the explanation of benefits form from the primary insurance carrier to the CMS 1500 Claim Form and complete boxes 9 9a‑d 11d and 29
bull Only one service per line and only six lines of service are allowed on a claim form
bull List only one provider per claimbull Individual rendering provider number must be
indicated in item 24k of the formbull Claim must be submitted within 180 days of service being renderedbull Do not enter the amount of the patientrsquos payment or the deductible in Item 29
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or in‑network providers who submit claims The RArsquos are designed to help providers identify claims that have been processed for their patients The RA includes claims that are paid denied or adjusted
We send a separate Remittance Advice ( RA) and payment check or electronic deposit for each of the following benefit programsbull Federal Employee Program (FEP)bull Indemnity CBA Blue Medicomp Vermont Health Partnership (VHP)bull Medicare Supplemental Programbull The Vermont Health Plan (TVHP)bull BlueCard amp Host Regional (NEHP)
Remittance advices are available in either paper or electronic format (PDF or 835) Paper remits and checks are mailed using the US Postal Service electronic remits are also available on the secure area of the bcbsvtcom website Please note Paper remits are not mailed to practicesproviders who received electronic payments See the reimbursement information in Section 1 for details on how to sign up for Electronic Payments
Electronic remits are retained for seven years
58
Claim Status
After initial submission including Medicare crossover claims wait at least thirty (30) days before requesting information on the status of the claim for which you have not received payment or denial After thirty (30) days there are several options to check the status of a claim
1 Unlimited inquires may be made through the BCBSVT website wwwbcbsvtcom
2 See Section Two (2) of this manual for information on how to access claims information on the web
3 Call one of the service lines listed in Section One (1) of this manual or
4 Submit a Payment Inquiry Form
Remittance Advice Discount of Charge Reporting
Due to our system calculations services that price at a discount off charge report the allowed amount as the charged amount The line is reported with a HIPAA adjustment code Paper remits report a 45 and 835rsquos (IampP) report a 131
Example If the provider bills in a charge of $10000 and the pricing is discount off charge (say 28) the allowance is $7200 On the remit the allowance will report $100 the payment (assuming no member liability) will reflect $7200 and a provider write off of $2800
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with a paper cover letter or on a paperelectronic error report informing the provider that the claim did not process through to a remittance advicemdashif a vendor or clearinghouse submits a claim on a providerrsquos behalf the report is returned directly to the vendor and not the provider office Claims could be returned for various reasons including but not limited to member unknown NPI not on file or incorrect place of service For electronic submitters a Returned Claim may be resubmitted electronically after the area of the claim that was in error is corrected For paper submissions resubmit as a clean claim only after correcting the area of the claim that was in error Never mark the resubmitted claims with any type of message as it will only result in a delay in processing
Corrected Claim
There are two types of claims that qualify as Corrected Claimsbull A claim that has processed through to a remittance advice but requires a specific correction such as but not limited to change in units change in date
of service billed amount of CPTHCPCS code orbull A Medicare primary claim in which CMS processes as part of a mass adjustment These types of claims are not automatically forwarded on to BCBSVT
for processing and have to be submitted on paper noting they are a corrected claim
Complete details on how to submit corrected claims are located on our provider website at wwwbcbsvtcom under reference guides then Correct claim submission guidelines
Corrected Claims for Exchange Members within their grace period
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or CMS 1500 types) for claims that are in month 2 or 3 of their grace period cannot be processed They should not be submitted to BCBSVT until after the claim has processed and reported to a remittance advice If you do happen to submit a correct claim or adjustment it will be returned directly to your office advising that the member is within their grace period and that the correct claim or adjustment can be submitted after payment is made or termination is complete
For full details on Exchange grace periods see ldquoGrace Period for Individual Through the Exchangerdquo
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a claim which has been processed and the provider is not in agreement with the contract rate amount of reimbursement or payment policy (for example denial for duplicate services which the provider believes were clinically appropriate)
A Claim Review request may be made directly by contacting our Customer Service Department or filed in writing using the Payment Inquiry Form Claim Review requests must be made within one hundred eighty (180) days from the original Remittance Advice
59
date All supporting documentation specific to the Claim Review must be supplied at the time of submission of the Provider Inquiry Form The Claim Review request will be reviewed and a letter of response provided pursuant to BCBSVT Policies
Member Confidential CommunicationsBCBSVT members have the ability to file for a confidential communication process
Facilities andor providers working with the members on this process need to have a strong process in place to notify their billing staff and place all claims submissions on hold until BCBSVT has confirmed the process is complete and claim(s) are ready to be submitted
See Section 3 for full details
ClaimCheck
BCBSVT utilizes Change Healthcare ClaimCheck software to assure accuracy and consistency in claims processing for all of our product lines (BCBSVT Federal Employee Program and BlueCard) for both professional (CMS 1500) and outpatient facility (UB04) based claims
This system applies all of the existing industry standard criteria and protocols for Current Procedural Terminology (CPT) Health Care Procedure Coding System (HCPCS) and the Internal Classification of Diseases (ICD‑10‑CM) manuals
The ClaimCheck software is upgraded twice a year An advanced notice is posted to the news area of our provider website at wwwbcbsvtcom advising of the upgrade date and any related details
These are the three most prevalent coding irregularities that we find
Unbundling Two or more individual CPT or HCPCS codes that should be combined under a single code or charge
Mutually Exclusive Two or more procedures that by practice standards would not be billed to the same patient on the same day
Inclusive Procedures Procedures that are considered part of a primary procedure and not paid as separate services
Consistent application of these rules improves the accuracy and fairness of our payment of benefits
ClaimCheck also applies the National Correct Coding Initiative (NCCI) Edits for the processing of both facility and professional claims Our updates of the NCCI will not align with the Centers for Medicare and Medicaid Services (CMS) we will always be at least one version behind
In addition ClaimCheck applies the appropriate Relative Value Unit for each service performed and processed in order of the RVU value RVU are constructed by the Centers for Medicare and Medicaid Services to display the relative intensity of resources required to care for a broad range of diseases and conditions
Exceptions to ClaimCheck logicbull Behavior Change Interventions
bull CPT codes 99408 and 99409 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99215 99281‑99285 99381‑99387 or 99391‑99397
bull After Hour Servicesbull CPT code 99050 are not subject to ClaimCheck logic when billed in addition to the following evaluation and management codes 99201‑99205 or
99211‑99215
BCBSVT has made available to you Clear Claim Connectiontrade (C3) C3 is a web‑based application that enables BCBSVT to disclose coding rules and edits rationale to our provider network Providers can access any of this information via our secure provider website (wwwbcbsvtcom) The system is designed to increase transparency and help BCBSVT educate our provider community on conceivably complex medical payments
60
You can locate C3 as followsbull wwwbcbsvtcom bull Go to the provider web areabull Sign into the secure provider websitebull Go to link titled ldquoClear Claim Connect (C3)bull There are two links one for professional claim logic and one for outpatient claim logic click on the applicable link
Providers can run claims through C3 for a determination of claims editing in advance of claim submission or after claim submission to explain the logic We encourage providers to use this tool to better understand the logic behind claims processing Please remember this is not tied to benefits payment policies medical policies etc and will only provide claim editing logic In addition the version of editing logic in our claim system does a claim look back (up to 99 lines) when editing so if you are inquiring about a service related to another service you will want to enter all services in the look‑up tool For example if an office visit occurs a day earlier than a surgery you would want to enter the office visit and date along with the surgery and date to make sure there is not any preoperative logic
ClaimCheck Logic Review A ClaimCheck Logic Review is a request by a provider for review of the logic supporting the processing of claims Prior to filing for a ClaimCheck review the processing of the claim should be reviewed through the Clear Claim Connect (C3) tool on the secure area of the BCBSVT Provider Website C3 will provide a full explanation of the logic behind the processing of the claim
A ClaimCheck Logic Review request may only be submitted in the following circumstance
A provider has locally or nationally recognized documentation that supports other possible logic If a provider disagrees with the ClaimCheck logic a request for review may be submitted by calling or writing to your Provider Relations Consultant within one hundred eighty (180) days from the original Remittance Advice date The provider will need to supply copies of all supporting documentation relied upon for use of a different logic than that currently in use by BCBSVT BCBSVT ClaimCheck Committee will review the information and notify the provider in writing of the final decision of the Plan
Note A ClaimCheck Review of a specific claim should not be filed If the claim was subject to extreme circumstances the BCBSVT Provider Claim Review process set forth above should be followed If when reviewing a denial of a claim based on ClaimCheck it is determined that a modifier or CPT code should be addedchanged the claim should be resubmitted as a Corrected Claim (as described above) BCBSVT stands behind all ClaimCheck logic and will uphold all denials for routine cases
Claim Specific GuidelinesIt is the intent and prerogative of BCBSVT to pay for necessary Medical surgical mental health and substance abuse services under our member contracts and in keeping with accepted and ethical medical practice
BCBSVT uses the Health Common Procedure Coding System (HCPCS) and the American Medical Associationrsquos Current Procedural Terminology (CPT) Diagnostic Coding must be according to the Internal Classification of Diseases (ICD‑10‑CM)
The Plan(s) require CPT HCPCS and ICD‑10‑CM codes to ensure that claims are processed promptly and accurately
This section provides guidelines for use in submitting claims for services provided to BCBSVT TVHP and BlueCard members (members from other Blue Plans) Topics are listed alphabetically Notifications on revisions to this section will be posted to the provider website or published in FinePoints the BCBSVTTVHP newsletter for providers
Medical policies and benefit restrictions related to these and other medical services are available at wwwbcbsvtcom or by calling your provider relations consultant
The BCBSVT Payment Policy Manual includes policies that document the principles used to make payment policy as well as policies documenting specific billingcoding guidelines and documentation requirements The Payment Policy Manual overview and payment policies are available on our secure provider website at wwwbcbsvtcom or by calling your provider relations consultant
61
BCBSVT reserves the right to conduct audits on any provider andor facility to ensure compliance with the guidelines stated in medical policy andor payment policies If an audit identifies instances of non‑compliance with a medical policy andor payment policy BCBSVT reserves the right to recoup all non‑compliant payments To the extent Plan seeks to recover interest Plan may cross‑recover that interest between BCBSVT and TVHP
Acupuncture
BCBSVT has a payment policy for acupuncture The policy defines eligible billable acupuncture services and how to bill for those services Only those services defined in the payment policy are to be billed to BCBSVT If other services are going to be rendered the requirements of a waiver defined in Section 1 must be satisfied When a waiver is on file non‑eligible services can be billed directly to the member Claims for non‑eligible services should not be billed to BCBSVT
Our payment policy for acupuncture is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies acupuncture
Allergy
For injection of commercially prepared allergens use the appropriate CPT code for administration For codes indicating ldquomore than __ testrdquo the specific number of tests should be indicated on the claim form in item 24g 1 unit = 1 test
Use the appropriate CPTHCPCS drug code if billing for the injected material
Ambulance Air
Must include the zip code of where the patient was picked up Details for claim submission below
Paper Claimsbull Form Locators 39 ‑ 41 AO (Numeric zero) in Value Codes sectionbull Form Locator 42 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
837 (Electronic Claims)bull Loop 2300 Segment CLM05 A0 (Nurmeric zero) in Value Codes sectionbull Loop 2300 Segment CLM02 In the amount column indicate the 5‑digit zip code in the dollar amount field where the patient is picked up
bull Submit the zip code in the following format 000ZZZZZ00bull Our system with truncate the leading zeros and post ZZZZZ00 if the zip code has a leading zero (05602) it will reflect as 560200
62
NOTE If you contract with more than one Plan in a state for the same product type (ie PPO or Traditional) you may file the claim with either Plan
Service Rendered
How to File (required fields)
Where to File Example
Air Ambulance Services
Point of pick‑up ZIP Code
bull Populate item 23 on CMS 1500 Health Insurance Claim Form with the 5‑digit ZIP code of the point of pick‑up
ndash For electronic billers populate the origin information (ZIP code of the point of pick‑up) in the Ambulance Pick‑up Location Loop in the ASC X12N Health Care Claim (837) Professional
bull Where Form CMS‑1450 (UB‑04) is used for air ambulance services not included with local hospital charges populate Form Locators 39‑41 with the 5‑digit ZIP code of the point of pick‑up The Form Locator must be populated with the approved Code and Value specified by the National Uniform Billing Committee in the UB‑04 Data Specifications Manual
ndash Form Locators (FL) 39‑41ndash Code AO (Special ZIP code reporting) or its successor code specified by the National Uniform Billing Committeendash Value Five digit ZIP Code of the location from which the beneficiary is initially placed on board the ambulancendash For electronic claims populate the origin information (ZIP code of the point of pickup in the Value Information Segment in the ASC X12N Health Care Claim (837) Institutional
File the claim to the Plan in whose service area the point of pick‑up ZIP code is located
BlueCard rules for claims incurred in an overlapping service area and contiguous county apply
bull The point of pick‑up ZIP code is in Plan A service areabull The claim must be filed to Plan A based on the point of pick‑up ZIP code
63
Ambulance Land
Report the ambulance pick‑up zip code on the claim submission
Paper claims need to report the pick‑up zip code in item 23 Electronic claims need to report the pick‑up zip code in loop 2310E
Ancillary Claim for BlueCard (defined as Durable Medical Equipment Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan which is the Plan in whose service area the ancillary services are rendered defined as follows
Independent Clinical Laboratory
The Plan in whose service area the specimen was drawn or collected (Place of Service 81 only)
Durable Medical Equipment
The Plan in whose service area the equipment was shipped to or purchased at a retail store
Specialty Pharmacy
The Plan in whose service area the ordering physician is located (Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms or 837 professional electronic submissions to identify the Local Plan The following information is required on all ancillary claim submissions If this information is missing we will return or reject these claims
Ancillary Claim Type
Local Plan
Identifier
CMS 1500 Box
Description
Loop on 837
Electronic Submission
Independent Clinical Laboratory
Referring Provider NPI
17B 2310A
Durable Medical Equipment
Referring Provider NPI
17B 2310A
Durable Medical Equipment
If Place of Service = Home PatientMember Address
5 or 7 2010CA or 2010BA
Durable Medical Equipment
If Place of Service ne Home Service Facility Location or Billing Provider Location
32 or 33 2310C or 2010AA
Speciality Pharmacy
Referring Provider NPI
17B 2310A
Not used to identify Local Plan for ancillary claim processing however required on all DME claims to support medical record processing
64
It is important to note that if you have a contract with the local Plan as defined above you must file claims to the local Plan and they will process as participatingnetwork provider claims If you do not have a contract with the local Plan you must still file claims with the local Plan but we will consider non‑participatingout‑of‑network claims
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendancemdash that is when the patient is safely placed under post‑anesthesia supervision Time during which the anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) are not in personal attendance is considered non‑billable time
Services involving administration of anesthesia should be reported using the applicable anesthesia five‑digit procedure codes (00100 ndash 01999) and if applicable the appropriate HCPC National Level II anesthesia modifiers andor anesthesia physical status (P1 ndash P6) modifiers as noted below
An anesthesia base unit value should not be reported Time units should be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Reimbursement for anesthesia services is based on the American Society of Anesthesiologist Relative Value Guide method pricing (time units + base unit value) x anesthesia coefficient Base unit values (BUVs) will automatically be included in the reimbursement
The following table identifies the source of each component that is utilized in the anesthesia pricing method
Component Source of InformationTime Units Submitted on the claim by the provider
Base Unit Value (BUV) Obtained from American Society of Anesthesiologist (ASA) Relative Value Guide
Anesthesia Coefficient Blue Cross and Blue Shield of Vermont (BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate for claims submitted by anesthesiologist andor certified registered nurse anesthetists (CRNAs) or anesthesia assistants (AAs) when reporting general anesthesia services
The term CRNAs include both qualified anesthetists and anesthesia assistants (AAs) thus from this point forward in guidelines the term CRNA will be used to refer to both categories of qualified anesthesiologists
CRNA Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-QS
Monitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QX
CRNA service with medical direction by a physician
Allows 50 of fee schedule payment based on the appropriate unit rate
-QZ
CRNA service without medical direction by a physician
Allows 100 of fee schedule payment based on the appropriate unit rate
65
Anesthesiologist Modifiers (please note these modifiers should always be billed in the first position of the modifier field)
Modifier Description BCBSVTTVHP Business Rules
-AA Anesthesia service performed personally by anesthesiologist
Unusual circumstances when it is medically necessary for both the CRNA and anesthesiologist to be completely and fully involved during a procedure 100 payment for the services of each provider is allowed Anesthesiologist would report ndashAA and CRNAndashQZ
-QK
Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals
Allows 50 of fee schedule payment based on the appropriate unit rate
-QSMonitored anesthesia care services
InformationalmdashModifier use will not impact reimbursement
-QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
Allows 50 of fee schedule payment based on the appropriate unit rate
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS) criteria for determination of Medical Direction and Medical Supervision
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified anesthetist The physician should
1 perform a pre‑anesthesia examination and evaluation
2 prescribe the anesthesia plan
3 personally participate in the most demanding procedures of the anesthesia plan including induction and emergence if applicable
4 ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist
5 monitor the course of anesthesia administration at intervals
6 remain physically present and available for immediate diagnosis and treatment of emergencies and
7 provide indicated post‑anesthesia care
If one or more of the above services are not performed by the anesthesiologist the service is not considered medical direction
66
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures Medical supervision also occurs when the seven required services under medical direction are not performed by an anesthesiologist This might occur in cases when the anesthesiologist
bull Left the immediate area of the operating suite for more than a short durationbull Devotes extensive time to an emergency case orbull Was otherwise not available to respond to the immediate needs of the surgical patients
Example An anesthesiologist is directing CRNAs during three procedures A medical emergency develops in one case that demands the anesthesiologistrsquos personal continuous involvement If the anesthesiologist is no longer able to personally respond to the immediate needs of the other two surgical patients medical direction ends in those two cases
Medical Supervision by a Surgeon In some small institutions nurse anesthetist performance is supervised by the operating provider (ie surgeon) who assumes responsibility for satisfying the requirement found in the state health codes and federal Medicare regulations pertaining to the supervision of nurse anesthetists Supervision services provided by the operating physician are considered part of the surgical service provided
Anesthesia Physical Status Modifiers (please note these modifiers should always appear in the second modifier field)
Modifier Description BCBSVTTVHP Business Rules
P1 A normal healthy patient
InformationalmdashModifier use will not impact reimbursement
P2 A patient with mild systemic disease
InformationalmdashModifier use will not impact reimbursement
P3 A patient with severe systemic disease
InformationalmdashModifier use will not impact reimbursement
P4A patient with severe systemic disease that is a constant threat to life
InformationalmdashModifier use will not impact reimbursement
P5A moribund patient who is not expected to survive without the operation
InformationalmdashModifier use will not impact reimbursement
P6A declared brain‑dead patient whose organs are being removed for donor purposes
InformationalmdashModifier use will not impact reimbursement
Electronic billing of anesthesia Electronic billing can either be in minutes or 8 ‑ 15 unit increments The appropriate indicator would need to be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics If billing minutes our system edits require that 16 or more are indicated If 15 minutes or less the claim is returned to the submitter Claims for 8 ‑ 15 minutes of anesthesia must be billed on paper Anesthesia reimbursement is always based on unit increments
67
therefore electronic claims submitted as minutes are translated by the BCBSVT system into 8 ‑ 15 minute unit increments Time units are translated 1‑unit for every 8 ‑ 15 minute interval Time duration of 8 minutes or more constitutes an additional unit
Paper billing of anesthesia Anesthesia services billed on paper can only be billed in unit increments (1‑unit for every 8 ‑ 15 minutes interval time duration of 8 ‑ 15 minutes constitutes an additional unit) If your claim does not qualify for at least 1‑unit (is less than 8 minutes) it should not be submitted to BCBSVT
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral procedure code use the appropriate CPT code for the first service and use the same code plus a modifier ndash50 for the second service
Biomechanical Exam
Use office visit codes for biomechanical exams
BlueCard Claims
See Section 7 for details
Breast Pumps
Specific guidelines for benefits and billing are available on our provider website at wwwbcbsvtcom under ldquoBreast pumps how to determine benefitsrdquo
Computer Assisted SurgeryNavigation
See Robotic amp Computer Assisted SurgeryNavigation later in this section for full details
Dental Anesthesia
Effective January 1 2018 there is a change to dental anesthesia codes D9222 and D9239 are new and D9223 and D9243 have been revised
New or Revised
HCPCS Code Description
New D9222 Deep sedationgeneral anesthesia ‑ first 15 minutesNew D9239 Intravenous moderate (conscious) sedationanalgesia ‑ first 15 minutesRevised D9223 Deep sedationgeneral anesthesia ‑ each subsequent 15 minute incrementRevised D9243 Intravenous moderate (conscious) sedationanalgesia ‑ each subsequent 15 minute increment
BCBSVT has designated D9222 and D9239 as single unit codes and D9223 and D9243 have been designated as multiple unit codes
Example of how services should be billed
Deep sedationgeneral anesthesia for 1 hour
D9222 ‑ 1 unit (equals 15 minutes) D9223 ‑ 3 units (equals 45 minutes)
Intravenous moderate (conscioius) sedationanalgesia for 1 hour
D9239 ‑ 1 unit (equals 15 minutes) D9243 ‑ 3 units (equals 45 minutes)
Time units need to be reported with 1‑unit for every 15 minute interval Time duration of 8 minutes or more constitutes an additional unit Reimbursement for these dental anesthesia services is based on the time units billed + base unit value x anesthesia coefficient therefore it is very important that you bill accordingly on one claim line Base unit values (BUVs) will automatically be included in the reimbursement
68
Example 47 minutes of deep sedation was provided to a patient
Bill one line of D9223 with a total of 3 units (the extra 2 minutes are written off per our anesthesia instructions)
If billing electronically services can either be in minutes or 8‑15 unit increments The appropriate indicator must be used to advise if the billing is units or minutes Please refer to our online companion guides for electronic billing for specifics or to the anesthesia instructions in this section of the provider manual for detailed instructions on anesthesia billing
Dental Care
FEP members have limited dental care available through the medical coverage and also have a supplemental dental policy available to them at an additional cost To learn more about FEP dental coverage and claim submission requirements refer to Section 9 FEP
Health Care Exchange members have benefits available for Pediatric Dental These members are identified by an alpha prefix of ldquoZIIrdquo or ldquoZIGrdquo and are age 21 or under They are covered through the end of the year of their 21st birthday
Members of an administrative services only (ASO) whose employer group has purchased dental coverage through BCBSVT are eligible through the BCBSVT Dental Medical Policy
The BCBSVT medical policy for dental services defines services and where prior approval and claims are to be submitted It has two sections Part A and Part B
The first section ldquoPart A defines all the services and requirements of the medical component for dental The Part A benefits are administered by BCBSVT and require the use of Blue Cross and Blue Shield contracted providers Prior approval requests and claim submissions are sent directly to BCBSVT
The second section ldquoPart B defines all the services and requirements for the pediatric dental benefits The Part B benefits are administered by CBA Blue and require the use of CBA Blue contracted providers Prior approval requests and claim submissions are sent directly to CBA Blue
Notebull CBA Blue responds to provider inquiries on dental services and claims related to Part B and BCBSVT respond to member inquiries related to Part B Pre‑
treatment or prior approval forms submitted to CBA Blue are responded to by CBA Blue using BCBSVT letterheadbull If services incorporate both Part A and Part B services and prior approval is required the prior approval needs to be submitted to BCBSVT We will
coordinate with CBA Blue for proper processing Claims can be split out and sent to both or if that is not possible you may submit directly to BCBSVT and we will coordinate the processing
Diagnosis Codes
BCBSVT claims process using the first diagnosis code submitted If you receive a denial related to a diagnosis code on a BCBSVT claim and there is another diagnosis on the claim that would be eligible you do not need to submit a corrected claim Just contact our customer service team either by phone e‑mail fax or mail and they will initiate a review andor adjustment Or if the diagnosis is truly in the wrong position you may submit a corrected claim updating the placement of the diagnosis
For BlueCard claims we send all reported diagnosis code(s) to the memberrsquos Plan If you wish to change the order of the diagnosis codes you must submit a corrected claim This corrected claim adjustment may or may not affect the benefit determination
Diagnostic Imaging Procedures
BCBSVT has a payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures The policy defines BCBSVT payment methodology when two or more payable diagnostic imaging procedures are performed on the same patient during the same session Our payment policy for Multiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures is located on the secure provider website at wwwbcbsvtcomprc under BCBSVT PoliciesPayment PoliciesMultiple Procedure Payment Reduction ‑ Diagnostic Imaging Procedures
69
Drugs Dispensed or Administered by a Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code (NDC) along with the unit of measure and quantity in addition to the applicable Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) codes(s) This requirement applies to drugs in the following categories
bull administrativebull miscellaneousbull investigationalbull radiopharmaceuticalsbull drugs ldquoadministered other than by oral methodrdquobull chemotherapy drugsbull select pathologybull laboratorybull temporary codes
The requirement does not apply to immunization drugs or to durable medical equipment
Acceptable values for the NDC Units of Measurement Qualifiers are as follows
Unit of Measure
Description
F2 International UnitGR GramME MilligramML MilliliterUN Unit
BCBSVT has the flexibility to accept the unit of measure reported in any nationally‑excepted value as well if you are not able to report the BCBSVT accepted values captured in the above table
Please refer to our online CMS (item number 24a and 24D) UB04 (form locator 42 and 44) instructions or HIPAA compliant 837I or 837P companion guide (section 111 NDC) for full billing details
Durable Medical Equipment
DME rentals require From and To dates on claims but the dates cannot exceed the date of billing
Evaluation and Management reminder Current Procedural Terminology (CPT) guidelines recognize seven components six of which are used in defining the levels of evaluation and management services These components are
bull Historybull Examinationbull Medical decision makingbull Counselingbull Coordination of carebull Nature of presenting problem and lastlybull Time
The first three of these components are considered the key components in selecting a level of evaluation and management services
70
The next three components are considered contributory factors in the majority of encounters Although counseling and coordination of care are important evaluation and management services these services are not required at every patient encounter
The final component time is provided as a guide however it is only considered a factor in defining the appropriate level of evaluation and management when counseling andor coordination of care dominates the physicianpatient andor family encounter Time is defined as face‑to‑face time such as obtaining a history performing and examination or counseling the patient CPT provides a nine‑step process that assists in determining how to choose the most appropriate evaluation and management code We apply this process when auditing medical and billing records and encourage all practicesproviders to become familiar with the nine step process Remember however the most important steps in terms of reimbursement and audit liability are verifying compliance and documentation If your practice utilizes a billing agent it is still the practicersquos responsibility to make sure correct coding of claims is occurring
Please refer to a CPT manual for full details on proper coding and complete documentation
Flu Vaccine and Administration
BCBSVT contracted providers facilities and home health agencies cannot bill members up front for the vaccine or administration The rendering provider facility or home health agency must submit the claim for services directly to BCBSVT
Every member who receives a flu shot must be billed separately BCBSVT does not allow for roster billing or billing of multiple patients on one claim
Both an administration and a vaccine code can be billed for the service
For billing of State‑supplied vaccinetoxoid please refer to instructions further down in this section
Habilitative Services
Some BCBSVT members have benefits available for habilitative services Habilitative services including devices are provided for a person to attain a skill or function never learned or acquired due to a disabling condition
When providing habilitative services for physical medicine occupational or speech therapy a modifier‑SZ (dates of service prior to 123117) or 96 (dates of service 1118 or after) must be reported so services will accumulate to the correct benefit limit
All other services for habilitative do not have any special billing requirements
Home Births
BCBSVT has a payment policy for Home Births The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Home Births is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Home Births
Home Infusion Therapy (HIT) Drug Services
HIT claims are to be billed the same as drugs dispensed or administered by a provider (other than pharmacy) Please refer to that section of the manual for full details
HIT providers who are on the community home infusion therapy fee schedule must bill procedure code 90378 (Synigis‑RSV) using the Average Wholesale Price (AWP) If you have questions please contact your provider relations consultant at (888) 449‑0443
Hospital Acquired Condition
See ldquoNever Events and Hospital Acquired Conditions in this section for full details
Hub and Spoke System for Opioid Addiction Treatment (Pilot Program)
BCBSVT has a payment policy for the Hub and Spoke System for Opioid Addiction Treatment The policy defines what the pilot program is benefit determinations and billing guidelines and documentation Our payment policy for Hub and Spoke System for Opioid Addiction Treatment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Hub and Spoke
71
Immunization Administration
CPT codes 90460 and 90461 should only be reported when a physician or other qualified health care professional provides face‑to‑face counseling to the patient and family during the administration of a vaccine This face‑to‑face encounter needs to be clearly documented to include scope of counseling and who provided counseling (include title(s)) to patient and parentscaregiver Proper signatures are also required to verify level of provider qualification Documentation is to be stored in the patientrsquos medical records
Qualified health care professional does not include auxiliary staff such as licensed practical nurses nursing assistants and other medical staff assistants
Each vaccine is administered with a base (CPT 90460) and an add‑on code (CPT 90461) when applicable
CPT codes 90460 and 90461 allows for billing of multiple units when applicable
Single line billing examples with counts
Example A Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90649 Human papilloma virus vaccine quadriv 3 dose im 1
2 90460 Immunization Administration 18 yr any route 1st vactoxoid 1
Example B Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90710 Measles mumps rubella varicella vacc live subq
1
2 90460 Immunization Administration through 18 yr any route 1st vactoxoid
1
3 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
3
Example C Single line billing multiple vaccines with combination toxoids
Line CPT-4 Description Unit Count
1 90698 Dtap‑hib‑ipv vaccine im 12 90670 Pneumococcal conj
vaccine 13 valent im1
3 90680 Rotavirus vaccine pentavalent 3 dose live oral
1
4 90460 Immunization Administration through 18 yr any route 1st vactoxoid
3
5 90461 Immunization Administration through 18 yr any route ea addl vactoxoid
4
If a patient of any age presents for vaccinations but there has been no face‑to‑face counseling the administration(s) must be reported with codes 90471 ndash 90474
72
See Ancillary Claims for BlueCard earlier in this section
Use the appropriate CPT code for administration of the injection If applicable submit the appropriate CPT andor HCPCS code for the injected material
Incident To
This is also referred to at times as supervised billing and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Inpatient Hospital Room and Board Routine Services Supplies and Equipment
BCBSVT has a payment policy for the Inpatient Hospital Room and Board Routine Services Supplies and Equipment The policy provides a description benefit determinations and billing guidelines and documentation Our payment policy for Inpatient Hospital Room and Board Routine Services Supplies and Equipment is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Inpatient Hospital Room and Board Routine Services Supplies and Equipment
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a specimen to an independent laboratory (not owned or operated by the physician) or hospital laboratory and the claim for the laboratory work is submitted by the physician Use place of service 11 in CMS 1500 item 24b
Laboratory Services (self-ordered by patient)
We require all laboratory services be ordered by a qualified health care provider If a patient has self‑ordered laboratory services(s) claim(s) cannot be billed to BCBSVT The member is financially liable and must be billed directly
Locum Tenens
Must be enrolled (See Section 1 for details) All services rendered by a locum tenens must be billed using their assigned NPI number in form locator 24J
Mammogram Screening and Screening Additional Views
BCBSVT has very specific coding requirements for screening mammograms and screening additional views (screening call backs) with a Breast Imaging Report and Data System (BI‑RADS) score of 0 (zero)
For an initial mammography that is a screening mammography the following coding will process at no member cost share
CPTHCPCS Code Primary ICD-10 Reporting77063 77067 (Append modifier ‑ 52 for unilateral exam)
Z0000 Z0001 Z1231 Z1239 Z803 Z853 Z9010 Z9011 Z9012 Z9013
For additional screening views or call backs if the initial screening mammography resulted in a Bi‑RADS 0 exam the following CPT amp ECD 10CM will be used and shall process at no member cost share No modifier is necessary to indicate screening
CPTHCPCS Code Primary ICD-10 Reporting76641 76642 77061 77062 77063 77065 77066 77067 G0279 (Append modifier ‑52 to report a unilateral exam)
R922 R928
73
Please also note that the date of service may be same day or a subsequent date if there is an additional mammogram or ultrasound required to complete the screening examination Examinations of the breast by other modalities may have cost share
While the national preventive care guidelines recommend screening mammography every one to two years BCBSVT does not require that members wait at least 365 days between medically necessary screening mammograms to access first‑dollar coverage
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
When applicable Member must have a benefit program that includes the Affordable Care Act first dollar preventive benefits
The Federal Employee Program and BlueCard benefits may not provide first‑dollar coverage For details on eligible mammography services contact the appropriate customer service team or Blue Plan
Maternity (Global) Obstetric Package
BCBSVT has a payment policy for Global Maternity Obstetric Package The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Global Maternity Obstetric Package is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Global Maternity Obstetric Package
Medically Unlikely Edits
BCBSVT follows the Centers for Medicare amp Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines
This program is administered by our partner Cotiviti At this time application of MUE is retrospective and is not processed through the ClaimCheck system
Mental HealthSubstance Abuse Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Mental HealthSubstance Abuse Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
The Policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Modifiers
The following payment rules apply when using these modifiersbull Modifier AS (physician assist nurse practitioner or clinical nurse specialist services for assistant surgery)mdash25 of allowed charge and 125 of
allowed charge for each secondary procedurebull Modifier GY (item or service statutorily excluded does not meet the definition of any Medicare benefit for non-Medicare insurers and is not a contracted
benefit) The GY modifier allows our system to recognize that the service or provider is statutorily excluded and to bypass the Medicare explanation of payment requirement The GY modifier can only be used when submitting claims for Medicare members when the service or provider is statutorily excluded by Medicare
74
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT The submission of these claims to BCBSVT allows us to apply your contracted rate so the claims will accurately process according to the memberrsquos benefits
bull In addition to the GY modifier the claim submission (paper or electronic) must indicate that Medicare is the memberrsquos primary carrier bull Claims that cross over to another Blue Plan from Medicare and contain services with a GY modifier will not be processed by the memberrsquos Blue
plan Instead either a letter or remittance denial will be issued alerting you that the claim must be submitted to your local Plan BCBSVT We do this so that our local Plan pricing is applied Services without the GY process using Medicarersquos allowance services with the GY needs ours
bull These claims will be returned or rejected with denial code 109 (claim not covered by this payercontractor) on the 835 or paper remits The paper remits will provide further information by way of remark code N418 Misrouted claim See the payerrsquos claim submission instructions
bull When submitting Medicare previously processed claims directly to BCBSVT include the original claim (with all lines including those without the GY modifier) and the Explanation of Medicare Benefits Lines that have previously paid through the memberrsquos Blue Plan will deny as duplicate and the lines with the GY modifiers will be processed according to the benefits the member has available
NOTE BCBSVT members with supplemental plan (typically have a prefix of ZIB) do not have benefits available in the absence of Medicare coveragebull Modifier GZ (item or services expected to be denied as not reasonable and necessary) is used as informational only and will not be reimbursed This
will report through to the remittance advice and report a HIPAA denial reason code 246 ldquoThis non‑payable code is for required reporting onlybull Modifier HO (Masters degree level) is used to report eligible Mental HealthSubstance Abuse Trainees (masters level psychiatric clinical nurse
specialist psychiatric mental health nurse practitioner psychiatrist or psychologist) when billing under their supervising provider It cannot be used for the initial evaluation
bull Modifier QK (Medical direction of two three or four concurrent anesthesia procedures involving qualified individuals)mdash50 of fee schedule payment based on the appropriate unit rate
bull Modifier QX (CRNA service with medical direction by a physician)mdash50 of fee schedule payment based on the appropriate unit ratebull Modifier QY (Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist)mdash50 of fee schedule payment based
on the appropriate unit ratebull Modifier SZ (habilitative services) Deleted modifier as of 010118 please use a modifier 96 ‑ When providing habilitative services for physical
medicine occupational or speech therapy a modifier‑SZ must be reported so services will accumulate to the correct benefit limitbull Modifier 54 (surgical care only)mdash85 of allowed charge for primary surgical procedurebull Modifier 55 (postoperative management only)mdash10 of allowed charge for primary surgical procedurebull Modifier 56 (preoperative management only)mdash5 of allowed charge for primary surgical procedurebull Modifier 81 (minimum assistant surgeon)mdash10 of allowed charge and 5 of allowed charge for each secondary procedurebull Modifier 82 (assistant surgeon when qualified resident surgeon is not available) 25 of allowed charge and 125 of allowed charge for each
secondary procedurebull Modifier 96 (habilitative services) ‑ when providing habilitative services for physical medicine occupational or speech therapy a modifier ‑ 96 must
be reported so services will accumulate to the correct benefit limit
Modifier 22 requires that office andor operative notes be submitted with the claim Claims without office andor operative notes if payable reimburse at a lower level Please refer to ‑22 Modifier Payment Policy on the secure provider website located under wwwbcbsvtcom under BCBSVT policies payment policy for complete guidelines
Modifiers -80 -82 and AS are only allowed when a surgical assistant assists for the entire surgical procedure Medical records must support the attendance of the assist from the beginning of the surgery until the end of the procedure
Modifier 81 is only allowed when the surgical assist is present for a part of the surgical procedure
Modifiers for Anesthesia please refer to Anesthesia section for specifics on usage
National Drug Code (NDC)
The reporting of an NDC is required for some claim types Refer to the section in this manual titled Drugs Dispensed or Administered by a Provider (other than pharmacy) or Home Infusion Therapy
75
Never Events and Hospital Acquired Conditions
The BCBSVT Quality Improvement Policy Never Events and Hospital Acquired Conditions Payment Policy provides all the details of what conditions are considered Never Events and Hospital Acquired Conditions investigations coding requirements and audits
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Providers and facilities are required to report these occurrences within 30 days from discovery of the event to BCBSVTrsquos quality improvement coordinator at QualityImprovementbcbsvtcom The email needs to include the patientrsquos name BCBSVT ID number date of service involved type of service name of attending physician and the name of person to contact if there are questions
Claims for these services should be submitted to BCBSVTTVHP for inpatient claims The present on admit indicator must be populated accordingly BCBSVT will not reimburse for any of the related charges The provider andor facility will be financially responsible for the cost of the extra care associated with the treatment of a BCBSVT or TVHP member following the occurrence of a never event
Not elsewhere classified (NEC) Not otherwise classified (NOS)
Providers should always bill a defined code when one is available If one is not available use an unlisted service (NEC or NOS) provide a description of the service along with office andor operative notes The note must accompany the original claim
Observation Services
BCBSVT has a payment policy for Observation Services The policy provides a description eligible and ineligible services and billing guidelines Our payment policy for Observation Services is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Observation ServicesOperating and Recovery Room Services and Supplies
BCBSVT has a payment policy for Operating and Recovery Room Services and Supplies The policy provides description eligible and ineligible services and billing guidelines Our payment policy for Operating and Recovery Room Services and Supplies is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Operating and Recovery Room Services and Supplies
Occupational Therapy Assistant (OTA)
OTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligible Their services must be directly supervised by an Occupational Therapist The supervising occupational therapist needs to be in the same building and available to the OTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for OTA services must be submitted under the supervising Occupational Therapistrsquos rendering national provider identifier
Physical Therapy Assistant (PTA)
PTArsquos are expected to practice within the scope of their license PTAs do not need to enroll or credential with BCBSVT to be eligibleTheir services must be directly supervised by a Physical Therapist The supervising physical therapist needs to be in the same building and available to the PTA at the time patient care is given Medical notes must be signed off by the supervising therapist Claims for PTA services must be submitted under the supervising Physical Therapistrsquos rendering national provider identifier
Place of Service
03 ‑ used to identify services in a school setting or school owned infirmary for services the provider has contracted directly with the school to provide
11 ‑ used for office setting or services provided in a school setting or school‑owned infirmary when the provider is not contracted with the school to provide the services
Pre-Operative and Post-Operative Guidelines
Some surgical procedures have designed pre andor post‑operative periods For those procedures (and associated timeframes) if an evaluation and management service is reported the service will deny
76
To determine if a surgery qualifies for pre andor post‑operative periods use the clear claim connect (C3) tool on the secure provider website Enter in the surgical code being performed along with the evaluation management code Make sure you indicate on each service line the specific date it will be or has been performed Or we have a complete listing on the secure provider website under the resource center clinical manuals pre and post‑operative manual
Pricing for Inpatient Claims
Claims apply the facility contractual reimbursement terms in effect on the date of admission for all facility claims
Provider-Based Billing
BCBSVT does not allow for provider‑based billing (ie billing a ldquofacility chargerdquo in connection with clinic services performed by a physician or other medical professional) Our payment policy for Provider‑Based Billing is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies provider based billing
Psychiatric Mental Health Nurse PractitionerPsychiatric Clinical Nurse Specialist Trainee
The trainee bills under the supervising provider who must be enrolled credentialed and in good standing with BCBSVT
The supervising provider bills for all services provided by the trainee using the modifier ‑ HO except the initial evaluation The initial evaluation needs to be billed without a modifier
Robotic amp Computer Assisted SurgeryNavigation
BCBSVT does not provide benefits for Robotic amp Computer Assisted SurgeryNavigation Our payment policy for Robotic amp Computer Assisted SurgeryNavigation is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Robotic amp Computer Assisted SurgeryNavigation
ldquoSrdquo Codes
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Specialty Pharmacy Claims
See Ancillary Claims for BlueCard earlier in the section
State Supplied VaccineToxoid
Must be submitted for data reporting purposes Use the appropriate CPT code for the vaccinetoxoid and the modifier ldquoSLrdquo (state supplied vaccine) and a charge of $000 If you submit through a vendor or clearinghouse that cannot accept a zero dollar amount a charge of $001 can be used
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231 99232 99233) are ldquoper dayrdquo services and need to be billed line by line
Substance AbuseMental Health Clinicians
If you are new to BCBSVT we have a useful orientation packet available on our provider website It provides guidance on how to work with BCBSVT including coding tips It is located in the provider area under the link for provider manualhandbook amp reference guidesnew provider orientationmental health and substance abuse clinician
Substance AbuseMental Health Trainee
The BCBSVT Quality Improvement Policy Supervised Practice of Mental Health and Substance Abuse Trainees provides the supervisortrainee requirements and claim submissioncoding requirements
77
The policy is located on the secure provider portal at wwwbcbsvtcom under BCBSVT Policies then the Quality Improvement link Or you can call your provider relations consultant for a paper copy
Supervised Billing
This is also referred to at times as incident to and is not allowed by BCBSVT Providers who render care to our members must be licensed credentialed and enrolled Exceptions are Therapy Assistants and Mental HealthSubstance Abuse Trainees Details on requirements for Therapy Assist and MHSA Trainees are contained within this section
Supplies
Submit using the appropriate CPTHCPCS code Charges submitted with an unspecified CPT code (99070) will be denied as non‑covered
Surgical Assistant
Benefits for one assistant surgeon may be provided during an operative session In the event that more than one physician assists during an operative session the total benefit for the assistant will not exceed the benefit for one Please use appropriate CPT coding
Not all surgeries qualify for a surgical assistant To determine if the assist you are providing is eligible for consideration use the clear claim connect (C3) tool on the secure provider website or review the listing of codes that always or never allow for a surgical assist on the secure provider website under the resource center clinical manuals assistant surgeon manual
Surgical Trays
When billing for a surgical tray members will need to bill HCPCS level II code A4550 along with the appropriate fee for the surgical tray No modifiers or units are allowed
Surgical tray benefits will only be considered when billed in conjunction with any surgical procedure for which use of a surgical tray is appropriate and when the procedure is performed in a physicianrsquos office rather than a separate surgical facility
To determine if a surgical tray is eligible for consideration use the clear claim connect (C3) tool on the secure provider website Enter in the services being performed along with the surgical tray code Alternately you may review the listing of codes that never allow for a surgical tray on the secure provider website under the resource center clinical manuals surgical tray manual
Telemedicine
BCBSVT has a payment policy for telemedicine The policy defines eligible telemedicine services and how the services need to be billed Our payment policy for telemedicine is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies telemedicine
Unit Designations
Each CPT and HCPCS code has a unit designation The designation is single or multiple
Single‑Unit Codes
bull You may only bill a code having a single‑unit designation to BCBSVT once on one claim line indicating one unit If you bill more than one claim line for a code with a single‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines as duplicates to the first line
bull Additionally you must bill claim lines with a single‑unit as one unit or we will deny the claim on the provider voucher (formerly called a remittance advice) for invalid units You must resubmit claims BCBSVT denies for invalid units as corrected claims
78
Multiple‑Units Codes
bull You may only bill a code having a multiple‑unit designation to BCBSVT as a single claim line with the amount of units indicated If you bill multiple claim lines for a service with a multiple‑unit designation BCBSVT will consider the first line for benefits and will deny all subsequent lines os duplicates to the first line You must submit a corrected claim to increase the unit value of the fist claim line if you need to bill more than one unit
A list of codes and their unit designations is available on our provider website at wwwbcbsvtcomprovider The list is not all inclusive If you do not locate your code on the list contact our customer service team
The unit designation list is updated quarterly to align with the AMAs updates for new deleted and revised codes
To request a review of a unit designation for a specific code you must contact your provider relations consultant and provide the code along with any supporting documentation you have that supports a code should be more than one unit A committee will review the request and if the committee deems a unit designation change appropriate it will be effective as of the date of the next quarterly CPTHCPCS adaptive maintenance cycle January April July and October
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics The policy defines what an urgent care clinic is (free standing or hospital based) and how the services need to be billed Our payment policy for Urgent Care Clinics is located on the secure provider portal at wwwbcbsvtcom under BCBSVT policies payment policies Urgent Care Clinics
Vision Services
Members covered through the Healthcare Exchange or employees with the State of Vermont may have vision services available to them We have created quick overview documents that define the services that are eligible and indicate where claims need to be submitted The overview documents are located on our secure website under resources reference guides vision services
79
Section 7 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to November 16 2017
For information related to claims with a date of service November 17 2017 or after please refer to our on‑line provider handbook
The BlueCardtrade Program Makes Filing Claims Easy
Introduction
As a participating provider of Blue Cross and Blue Shield of Vermont you may render services to patients who are national account members of other Blue Cross andor Blue Shield Plans and who travel or live in Vermont
This manual is designed to describe the advantages of the program while providing you with information to make filing claims easy This manual offers helpful information about
bull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
What is the BlueCardtrade Program
a Definition
The BlueCard program is a national program that enables members obtaining health care services while traveling or living in another Blue Cross and Blue Shield Planrsquos area to receive all the same benefits of their contracting BCBS Plan including provider access and discounts on services negotiated by the local plans The program links participating health care providers and the independent BCBS Plans across the country and around the world through a single electronic network for claims processing
The program allows you to submit claims for patients from other Blue Plans domestic and international to BCBSVT
BCBSVT is your sole contact for claims payment problem resolution and adjustments
b BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit claims for members from other Blue Plans including international Blue Plans directly to BCBSVT
BCBSVT will be your one point of contact for all of your claims‑related questions
BCBSVT continues to experience growth in out‑of‑area membership because of our partnership with you That is why we are committed to meeting your needs and expectations In doing so your patients will have a positive experience with each visit
c Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Programbull stand‑alone dental bull prescription drugsbull the Federal Employee Program (FEP)
80
How Does the BlueCard Program Work
How to Identify Members
a Member ID Cards
When members of another Blue Plan arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card
The main identifier for out‑of‑area members is the alpha prefix The ID cards may also havebull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
Important facts concerning member IDsbull A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters up to 17 positions total This means that you
may see cards with ID numbers between 6 and 14 numbersletters following the alpha prefixbull Do not adddelete characters or numbers within the member IDbull Do not change the sequence of the characters following the alpha prefixbull The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Planbull Some Blue Plans issue separate identification numbers to members with Blue Cross (Inpatient) and Blue Shield (Professional) coverage Member ID
cards may have different alpha prefixes for each type of coverage
As a provider servicing out‑of‑area members you may find the following tips helpfulbull Ask the member for the current ID card at every visit Since new ID cards may be issued to members throughout the year this will ensure tha you
have the most up‑to‑date information in your patientrsquos filebull Verify with the member that the number on the ID card is not hisher Social Security Number If it is call the BlueCard Eligibility line at
(800) 676‑BLUE (2583) to verify the ID numberbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staffbull 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 memberrsquos ID numbers
Alpha Prefix
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
The prefix is followed by the member identification number It can be any length and can consist of all numbers all letters or a combination of both letters and numbers
81
To ensure accurate claim processing it is critical to capture all ID card data If the information is not captured correctly you may experience a delay with the claim processing Please make copies of the front and the back of the ID card and pass the key information to your billing staff
Sample ID Cards
Occasionally you may see identification cards from foreign Blue members including foreign Blue members living abroad These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
NOTE The Canadian Association of Blue Cross Plans and its members are separate and distinct from the Blue Cross and Blue Shield Association and its members in the US
The ldquosuitcaserdquo logo may appear anywhere on the front of the card
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
PREADMISSION REVIEW REQUIRED
BS PLAN915
BC PLAN415
GROUP NUMBER
00000000
IDENTIFICATION NUMBER
XYZ123456789XYZ
RESTAT0451
MEMBER NAME
CHRIS B HALL
The three‑character alpha prefix
82
Sample Foreign ID Cards
If you are unsure about your participation status call BCBSVT
b Consumer Directed Health Care and Health Care Debit Cards Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior
Health plans that offer CDHC provide the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Members who have CDHC plans often carry health care debit cards that allow them to pay for out‑of‑pocket costs using funds from their Health Reimbursement Arrangement (HRA) Health Savings Account (HSA) or Flexible Spending Account (FSA)
Some cards are ldquostand‑alonerdquo debit cards to cover out‑of‑pocket costs while others also serve as a member ID card with the member ID number These debit cards can help you simplify your administration process and can potentially help
bull Reduce bad debt bull Reduce paper work for billing statementsbull Minimize bookkeeping and patient‑account functions for handling cash and checksbull Avoid unnecessary claim payment delays
83
The card will have the nationally recognized Blue logos along with a major debit card logo such as MasterCardreg or Visareg
Sample stand-alone Health Care Debit Card
Sample Combined Health Care Debit Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card at the point of service to collect the member cost sharing amount (ie co‑payment) With the health debit cards members can pay for co‑payments and other out‑of‑pocket expenses by swiping the card through any debit card swipe terminal The funds will be deducted automatically from the memberrsquos appropriate HRA HSA or FSA account
Combining a health insurance ID card with a source of payment is an added convenience to members and providers Members can use their cards to pay outstanding balances on billing statements They can also use their cards via phone in order to process payments In addition members are more likely to carry their current ID cards because of the payment capabilities
If your office accepts credit card payments you can swipe the card at the point of service to collect the memberrsquos co‑payment coinsurance or deductible amount Simply select ldquocreditrdquo when running the card through for payment No PIN is required The funds will be sent to you and will be deducted automatically from the memberrsquos HRA HSA or FSA account
84
Helpful Tipsbull Carefully determine the memberrsquos financial responsibility before processing payment You can access the memberrsquos accumulated deductible by
contacting the BlueCard Eligibility line at (800) 676‑BLUE (2583) or by using the local Planrsquos online servicesbull Ask members for their current member ID card and regularly obtain new photocopies (front and back) of the member ID card Having the current card
will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claims payment delaysbull If the member presents a debit card (stand‑alone or combined) be sure to verify the out‑of‑pocket amounts before processing payment
bull Many plans offer well care services that are payable under the basic health care program If you have any questions about the memberrsquos benefits or to request accumulated deductible information please contact (800) 676‑BLUE (2583)
bull You may use the debit card for member responsibility for medical services provided in your officebull You may choose to forego using the debit card and submit the claims to BCBSVT for processing The Remittance Advice will inform you of member
responsibilitiesbull All services regardless of whether yoursquove collected the member responsibility at the time of service must be billed to the local Plan for proper
benefit determination and to update the memberrsquos claim history
bull Check eligibility and benefits electronically (local Planrsquos contact infowebsite address) or by calling (800) 676‑BLUE (2583) and providing the alpha prefix
bull Please do not use the card to process full payment up front If you have any questions about the memberrsquos benefits please contact (800) 676‑BLUE (2583) or for questions about the health care debit card processing instructions or payment issues please contact the toll‑free debit card administratorrsquos number on the back of the card
c Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing
Each Blue Cross and Blue Shield plan has its own terms of coverage There may be exclusions or requirements you are not familiar with Each plan may also have a different co‑payment application that is based on provider speciality For example a nurse practitioner or physician assistant in a primary care practice setting may apply a specialist co‑payment rather than a PCP co‑payment Some Blue Plans may exclude the use of certain provider specialties such as naturopath acupuncture or athletic trainers Some members may have only Blue Cross (Inpatient) or only Blue Shield (Professional) coverage with their Blue Plan so verifying eligibility is extremely important There are two methods of verification available
ElectronicmdashSubmit an electronic transaction via the tool located on the provider web site at wwwbcbsvtcom Please refer to the manual located in the section for specific details
PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583) A representative will ask you for the alpha prefix and will connect you to the membership and coverage unit at the patientrsquos Blue Cross andor Blue Shield Plan
If you are using the BlueCard Eligibilityreg line keep in mind that Blue Plans are located throughout the country and may operate on a different time schedule than Vermont You may be transferred to a voice response system linked to customer enrollment and benefits
The BlueCard Eligibilityreg line is for eligibility benefit and pre‑certificationreferral authorization inquiries only It should not be used for claim status See the Claim Filing section for claim filing information
85
d Utilization Review
BCBSVT participating facilities are responsible for obtaining pre‑service review for inpatient services for BlueCardreg members Members are held harmless when pre‑service review is required by the account or member contract and not received for inpatient services Participating providers must also
bull Notify the memberrsquos Blue Plan within 48 hours when a change or modification to the original pre‑service review occursbull Obtain pre‑service review for emergency andor urgent admissions within 72 hours
Failure to contact the memberrsquos Blue Plan for pre‑service review or for a change of modification of the pre‑service review may result in a denial for inpatient facility services The remittance advice will report the service as a provider write‑off and the BlueCardreg member must be held harmless and cannot be balance‑billed if a pre‑service review was not obtained
On inclusively priced claims such as DRG or Per Diem if you bill more days than were authorized the full claims may be denied in some instances
Services that deny as not medically necessary remain member liability
Pre‑service review contact information for a memberrsquos Blue Plan is provided on the memberrsquos identification card Pre‑service review requirements can also be determined by
bull Callling the pre‑admission review number on the back of the memberrsquos cardbull Calling the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Calling (800) 676‑BLUE (2583) if you do not have the memberrsquos card and asking to be transferred to the utilization review areabull Using the Electronic Provider Access (EPA) tool available at BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard You should always submit claims to BCBSVT
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 676‑BLUE (2583) Be sure to provide the memberrsquos alpha prefixbull Verify the memberrsquos cost sharing amount before processing payment Please do not process full payment upfrontbull Indicate on the claim any payment you collected from the patient (On the 837 electronic claim submission form check field AMT01=F6 patient paid
amount on the CMS1500 locator 29 amount paid on UB92 locator 54 prior payment on UB04 locator 53 prior payment)bull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the three‑character alpha prefixSubmit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
86
Providers who render services in contiguous counties contract with other Blue Plans or have secondary locations outside the State of Vermont may not always submit directly to BCBSVT We have three guides (Vermont and New Hampshire Vermont and Massachusetts Vermont and New York) to help you determine where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
1 Member ofanother Blue Planreceives servicesfrom youthe provider
2 Providersubmits claim tothe local Blue Plan
3 Local Blue Planrecognizes BlueCardmember and transmitsstandard claim format tothe the memberrsquos Blue Plan
4 Memberrsquos BluePlan adjudicatesclaim according tomemberrsquos benefit plan
5 Memberrsquos Blue Planissues an EOB tothe member
6 Memberrsquos BluePlan transmits claimpayment dispositionto your local Blue Plan
7 Your localBlue Plan paysyou the provider
bull Upon receipt BCBSVT will electronically route the claim to the memberrsquos Blue Plan The memberrsquos Plan then processes the claim and approves
payment BCBSVT will reimburse you for servicesbull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims
payment process and creates confusion for the memberbull Check claims status by contacting BCBSVT at (800) 395‑3389
Medicare Advantage Overview
ldquoMedicare Advantagerdquo (MA) is the program alternative to standard Medicare Part A and Part B fee‑for‑service coverage generally referred to as ldquotraditional Medicarerdquo
MA offers Medicare beneficiaries several product options (similar to those available in the commercial market) including health maintenance organization (HMO) preferred provider organization (PPO) point‑of‑service (POS) and private fee‑for‑service (PFFS) plans
All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits but many offer additional covered services as well (eg enhanced vision and dental benefits)
In addition to these products Medicare Advantage organizations may also offer a Special Needs Plan (SNP) which can limit enrollment to subgroups of the Medicare population in order to focus on ensuring that their special needs are met as effectively as possible
Medicare Advantage plans may allow in‑ and out‑of‑network benefits depending on the type of product selected Providers should confirm the level of coverage (by calling (800) 676BLUE (2583) or submitting an electronic inquiry) for all Medicare Advantage members prior to providing service since the level of benefits and coverage rules may vary depending on the Medicare Advantage plan
87
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals Generally (except in urgent or emergency care situations) medical services are only covered when provided by in‑network providers The level of benefits and the coverage rules may vary by Medicare Advantage plan
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs It allows members to determinemdashat the point of servicemdashwhether they want to receive certain designated services within the HMO system or seek such services outside the HMOrsquos provider network (usually at greater cost to the member) The Medicare Advantage POS plan may specify which services will be available outside of the HMOrsquos provider network
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers Required member cost‑sharing may be greater when covered services are obtained out‑of‑network Medicare Advantage PPO plans may be offered on a local or regional (frequently multi‑state) basis Special payment and other rules apply to regional PPOs
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may go to any Medicare‑approved doctor or hospital that accepts the planrsquos terms and conditions of participation Acceptance is deemed to occur where the provider is aware in advance of furnishing services that the member is enrolled in a PFFS product and where the provider has reasonable access to the terms and conditions of participation
The Medicare Advantage organization rather than the Medicare program pays physicians and providers on a fee‑for‑services basis for services rendered to such members Members are responsible for cost‑sharing as specified in the plan and balance billing may be permitted in limited instances where the provider is a network provider and the plan expressly allows for balance billing
Medicare Advantage PFFS varies from the other Blue products you might currently participate in
88
bull If you do provide services you will do so under the Terms and Conditions of that memberrsquos Blue Plan bull Please refer to the back of the memberrsquos ID card for information on accessing the Planrsquos Terms and Conditions You may choose to render services to a
MA PFFS member on an episode of care (claim‑by‑claim) basisbull MA PFFS Terms and Conditions might vary for each Blue Cross andor Blue Shield Plan We advise that you review them before servicing MA PFFS
members
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a Medicare health plan option made up of two parts One part is a Medicare MSA Health Insurance Policy with a high deductible The other part is a special savings account where Medicare deposits money to help members pay their medical bills
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card instead a Blue Cross andor Blue Shield logo will be visible on the ID card The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards
Eligibility Verificationbull Verify eligibility by contacting (800) 676‑BLUE (2583) and providing an alpha prefix or by submitting an electronic inquiry to your local Plan and
providing the alpha prefix bull Be sure to ask if Medicare Advantage benefits apply bull If you experience difficulty obtaining eligibility information please record the alpha prefix and report it to your local Plan contact
Medicare Advantage Claims Submissionbull Submit all Medicare Advantage claims to BCBSVT bull Do not bill Medicare directly for any services rendered to a Medicare Advantage member bull Payment will be made directly by a Blue Plan
Traditional Medicare-Related Claims
1 The following are guidelines for processing of Medicare‑related claims
When Medicare is primary payer submit claims to your local Medicare intermediarybull After you receive the Remittance Advice (RA) from Medicare review the indicatorsbull If the indicator on the RA (claim status code 19) shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan
and the claim is in progress You can make claim status inquiries for supplemental claims through BCBSVTbull If the claim was not crossed over (indicator on the RA will not show claim status code 19 and may show claim status code 1) submit the claim to
BCBSVT along with the Medicare remittance advice You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
2 Do not submit Medicare‑related claims to BCBSVT before receiving an RA from the Medicare intermediary
3 If you use Other Carrier Name and Address (OCNA) number on a Medicare claim ensure it is the correct member for the memberrsquos Blue Plan Do not automatically use the OCNA number for BCBSVT
4 Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through an electronic transaction via the BlueExchange tool
89
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire Vermont and Massachusetts and Vermont and New York) to assist you with knowing where to submit claims in these circumstances These guides are located on our provider website at wwwbcbsvtcom
International Claims
The claim submission process for international Blue Plan members is the same as for domestic Blue members You should submit the claim directly to BCBSVT
Medical Records
There are times when the memberrsquos Blue Plan will require medical records to review the claim These requests will come from BCBSVT Please forward all requested medical records to BCBSVT and we will coordinate with the memberrsquos Blue Plan Please direct any questions or inquiries regarding medical records to Customer Service at (800) 395‑3389 Please do not proactively send medical records with the claim unless requested Unsolicited claim attachments may cause claim payment delays
Adjustments
Contact BCBSVT if an adjustment is required We will work with the memberrsquos Blue Plan for adjustments however your workflow should not be different
Appeals
Appeals for all claims are handled through BCBSVT We will coordinate the appeal process with the memberrsquos Blue Plan if needed
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment
If you discover the member is covered by more that one health plan and
a BCBSVT or any other Blue Plan is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVT If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which will increase your volume of bookkeeping
b Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from the primary payer including the explanation of payment from the primary carrier If you do not include the COB information with the claim the memberrsquos Blue Plan will have to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Claim Payment
1 If you have not received payment for a claim do not resubmit the claim because it will be denied as a duplicate This also causes member confusion because of multiple Summary of Health Plans
2 If you do not receive your payment or a response regarding your payment please call BCBSVT Customer Service at (800) 395‑3389 or submit an electronic transaction via the provider tool at wwwbcbsvtcom to check the status of your claim
3 In some cases a memberrsquos Blue Plan may pend a claim because medical review or additional information is necessary When resolution of a pended claim requires additional information from you BCBSVT may either ask you for the information or give the memberrsquos Plan permission to contact you directly
90
Claim Status Inquiry
1 BCBSVT is your single point of contact for all claim inquiries
2 Claim status inquires can be done by
Phonemdashby calling BCBSVT customer Service at (800) 395‑3389 Electronicallymdashsend an electronic transaction via the provider tool
Calls from Members and Others with Claim Questions
1 If members contact you advise them to contact their Blue Plan and refer them to their ID card for a customer service number
2 The memberrsquos Plan should not contact you directly regarding claims issues but if the memberrsquos Plan contacts you and asks you to submit the claim to them refer them to BCBSVT
Frequently Asked Questions
BlueCard Basics
1 What Is the BlueCardreg Program
BlueCardreg is a national program that enables members of one Blue Plan to obtain healthcare services while traveling or living in another Blue Planrsquos service area The program links participating health care providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement
The program allows you to conveniently submit claims for patients from other Blue Plans domestic and international to your local Blue Plan
Your local Blue Plan is your sole contact for claims payment problem resolution and adjustments
2 What products and accounts are excluded from the BlueCard Program
Stand‑alone dental and prescription drugs are excluded from the BlueCard Program In addition claims for the Federal Employee Program (FEP) are exempt from the BlueCard Program Please follow your FEP billing guidelines
3 What is the BlueCard Traditional Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area a traditional or indemnity level of benefits when they obtain services from a physician or hospital outside of their Blue Planrsquos service area
4 What is the BlueCard PPO Program
Itrsquos a national program that offers members traveling or living outside of their Blue Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
5 Are HMO patients serviced through the BlueCard Program
Yes occasionally Blue Cross andor Blue Shield HMO members affiliated with other Blue Plans will seek care at your office or facility You should handle claims for these members the same way you handle claims for BCBSVT members and Blue Cross andor Blue Shield traditional PPO and POS patients from other Blue Plansmdashby submitting them to BCBSVT
Identifying Members and ID Cards
1 How do I identify members
When members from Blue Plans arrive at your office or facility be sure to ask them for their current Blue Plan membership identification card The main identifier for out‑of‑area members is the alpha prefix The ID cards may also have
bull PPO in a suitcase logo for eligible PPO membersbull Blank suitcase logo
91
2 What is an ldquoalpha prefixrdquo
The three‑character alpha prefix at the beginning of the memberrsquos identification number is the key element used to identify and correctly route claims The alpha prefix identifies the Blue Plan or national account to which the member belongs It is critical for confirming a patientrsquos membership and coverage
3 What do I do if a member has an identification card without an alpha prefix
Some members may carry outdated identification cards that do not have an alpha prefix Please request a current ID card from the member
4 How do I identify international members
Occasionally you may see identification cards from foreign Blue Plan members These ID cards will also contain three‑character alpha prefixes Please treat these members the same as domestic Blue Plan members
Verifying Eligibility and Coverage
How do I verify membership and coverage
For Blue Plan members use the BlueExchange Link on the BCBSVT web site or call the BlueCard Eligibilityreg phone line to verify the patientrsquos eligibility and coverage
Electronicmdashvia the BlueExchange link on the provider secure website at BCBSVTcom PhonemdashCall BlueCard Eligibilityreg (800) 676‑BLUE (2583)
Utilization Review
How do I obtain utilization reviewbull Call the pre‑admission review number on the back of the memberrsquos cardbull Call the customer service number on the back of the memberrsquos card and asking to be transferred to the utilization review areabull Call (800) 676‑BLUE (2583) if you do not have the memberrsquos card and ask to be transferred to the utilization review areabull Use the Electronic Provider Access (EPA) tool available at the BCBSVT provider portal at wwwbcbsvtcom With EPA you can gain access to a BlueCard
memberrsquos Blue Plan provider portal through a secure routing mechanism and have access to electronic pre‑service review capabilities Note the availability of EPA will vary depending on the capabilities of each memberrsquos Blue Plan
For Blue Plans members
PhonemdashCall the utilization managementpre‑certification number on the back of the memberrsquos card If the utilization management number is not listed on the back of the memberrsquos card call BlueCard Eligibilityreg (800) 676‑BLUE (2583) and ask to be transferred to the utilization review area
Claims
1 Where and how do I submit claims
You should always submit claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you submit the claim The complete identification number includes the three‑character alpha prefix (Do not make up alpha prefixes) Claims with incorrect or missing alpha prefixes and member identification numbers cannot be processed
2 How do I submit international claims
The claim submission process for international Blue Plan members is the same as for domestic Blue Plan members You should submit the claim directly to BCBSVT
92
3 How do I handle Medicare-related claimsbull When Medicare is a primary payer submit claims to your local Medicare intermediary After receipt of the Remittance Advice (RA) from Medicare
review the indicatorsbull If the indicator on the RA shows that the claim was crossed‑over Medicare has submitted the claim to the appropriate Blue Plan and the claim
is in process You can make claim status inquiries for supplemental claims through BCBSVT bull If you have any questions regarding the crossover indicator please contact the Medicare intermediary
bull Do not submit Medicare‑related claims to your local Blue Plan before receiving an RA from the Medicare intermediarybull If you are using an OCNA number on the Medicare claim ensure it is the correct OCNA number for the memberrsquos Blue Plan Do not automatically use
the OCNA number for the local Host Plan or create an OCNA number of your ownbull Do not create alpha prefixes For an electronic HIPAA 835 (Remittance Advice) request on Medicare‑related claims contact BCBSVTbull If you have Other Party Liability (OPL) information submit this information with the Blue claim Examples of OPL include Workersrsquo Compensation and
auto insurancebull Do not send duplicate claims First check a claimrsquos status by contacting BCBSVT by phone or through the BlueExchange link
Glossary of BlueCard Program TermsAlpha Prefix Three characters preceding the subscriber identification number on the Blue Plan ID cards The alpha prefix identifies the memberrsquos Blue Plan or national account and is required for routing claims
BCBScom Blue Cross and Blue Shield Associationrsquos Web site which contains useful information for providers
BlueCard Accessregmdash(800) 810-BLUE (2583) or wwwBCBScomhealthtravelfinderhtml A toll‑free number and website for you and members to use to locate health care providers in another Blue Planrsquos area This number is useful when you need to refer the patient to a physician or health care facility in another location
BlueCard Eligibilityreg (800) 676-BLUE (2583) A toll‑free number for you to verify membership and coverage information and obtain pre‑certification on patients from other Blue Plans
BlueCard PPO A national program that offers members traveling or living outside of their Blue Cross andor Blue Shield Planrsquos area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider
BlueCard PPO Member Someone who carries an ID card with this identifier on it Only members with this identifier can access the benefits of the BlueCard PPO
BlueCard Doctor amp Hospital Finder website wwwBCBScomhealthtravelfinderhtml A website you can use to locate health care providers in another Blue Cross andor Blue Shield Planrsquos areamdashwwwbcbscomhealthtravelfinderhtml This is useful when you need to refer the patient to a physician or healthcare facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
BlueCard Worldwidereg A program that allows Blue members traveling or living abroad to receive nearly cashless access to covered inpatient hospital care as well as access to outpatient hospital care and professional services from health care providers worldwide The program also allows members of foreign Blue Cross andor Blue Plans to access domestic (US) Blue provider networks
Consumer Directed Health CareHealth Plans (CDHCCDHP) Consumer Directed Health Care (CDHC) is a broad umbrella term that refers to a movement in the health care industry to empower members reduce employer costs and change consumer health care purchasing behavior CDHC provides the member with additional information to make an informed and appropriate health care decision through the use of member support tools provider and network information and financial incentives
Coinsurance A provision in a memberrsquos coverage that limits the amount of coverage by the benefit plan to a certain percentage The member pays any additional costs out‑of‑pocket
93
Coordination of Benefits (COB) Ensures that members receive full benefits and prevents double payment for services when a member has coverage from two or more sources The memberrsquos contract language gives the order for which entity has primary responsibility for payment and which entity has secondary responsibility for payment
Co-payment A specified charge that a member incurs for a specified service at the time the service is rendered
Deductible A flat amount the member incurs before the insurer will make any benefit payments
Hold Harmless An agreement with a health care provider not to bill the member for any difference between billed charges for covered services (excluding coinsurance) and the amount the healthcare provider has contractually agreed on with a Blue Plan as full payment for these services
Medicare Crossover The Crossover program was established to allow Medicare to transfer Medicare Summary Notice (MSN) information directly to a payer with Medicarersquos supplemental insurance company
Medicare Supplemental (Medigap) Pays for expenses not covered by Medicare
National Account An employer group that has offices or branches in more than one location but offers uniform coverage benefits to all of its employees
Other Party Liability (OPL) A cost containment program that recovers money where primary responsibility does not exist because of another group health plan or contractual exclusions Includes coordination of benefits workersrsquo compensation subrogation and no‑fault auto insurance
Plan Refers to any Blue Cross andor Blue Shield Plan
BlueCard Program Quick TipsThe BlueCard Program provides a valuable service that lets you file all claims for members from other BC andor BS Plans with your local Plan
Key points to rememberbull Make a copy of the front and back of the memberrsquos ID cardbull Look for the three‑character alpha prefix that precedes the memberrsquos ID number on the ID cardbull Call BlueCard Eligibility at (800) 676‑BLUE to verify the patientrsquos membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to
the local Planbull Submit the claim to BCBSVT PO Box 186 Montpelier VT 05601 Always include the patientrsquos complete identification number which includes the
three‑character alpha prefixbull For claims inquiries call BCBSVT (800) 924‑3494
94
Section 8 Blue Cross and Blue Shield of Vermont and the Blueprint ProgramOverview
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide partnership to improve health and the health care system for Vermonters The Blueprint provides information tools and support that Vermonters with chronic conditions need to manage their own health The Blueprint is working to change health care to a system focused on preventing illness and complications rather than reacting to health emergencies
The Blueprint for Health program comprises Patient Center Medical Homes supported by Coummunity Health Teams (CHT) and a health information technology infrastructure The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients their families and their personal physicians Information technololgy tools such as patient registries data tracking and health information exchanges provide a basis for this patient‑centered healthcare facilitating guideline‑based care reporting and healthcare modeling
More information is available on the Blueprint home page located httpblueprintforhealthvermontgov
BCBSVT has also published detailed articles in our provider publication Finepoints (Summer 2012 Fall 2012 and Winter 2012‑2013)
Enrollment into the Blueprint program is done through the Department of Vermont Health Access (DVHA) Blueprint Staff To learn more about the Blueprint and the requirements to become a recognized National Committee for Quality Assurance Physician Practice Connectionsreg ‑ Patient‑Centered Medical Hometrade (PPCreg‑PCMHtrade) please refer to the Vermont Blueprint for Health Implementation Manual located here on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Implementation Materials
Bulletin 10‑19‑Vermont Blueprint for Health Rules (Adopted 3511) Blueprint Manual (Nov 2010)
Blueprint Notifications and Staff Contact Information
Contact Blueprint Staff directly Information is available here on the Blueprint website httpblueprintforhealthvermontgov
BCBSVT required Participating Practice DemographicPayment Information
BCBSVT requirements align with the final and adopted PPPM Attribution Physician Practice Roster used by all insurers for attribution located here on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group ‑ Payment Roster Template
95
Below is a listing of the physician practice roster data elements required by BCBSVT These data elements are used by BCBSVT to complete a demograhic reconciliation against our provider files and ensure appropriate Blueprint set up
bull Primary Care Provider First Name bull Primary Care Provider Last Namebull Provider Credentials (MDDO APRN PA)bull Providerrsquos Primary Scope of Practicebull Primary Care or Specialist Indicator (indicate PCP SPECIALIST or BOTH)bull Provider Phone Numberbull Individual Provider NPIbull Provider Term Datebull Parent Organization (if FQHC RHC CAH group or hospital‑owned practice)bull Primary Care Practice Site Name (name on the door)bull Primary Care Practice Namebull Practice Physical Addressbull Citybull Statebull Zip Codebull Practice or Group National Provider Identifier (NPI) for Paymentbull Practice Tax ID
The following physician practice roster information is used to ensure appropriate communications between the PCMH and BCBSVT More than one person can be listed in each category (Pay‑to or Reports Contact)
bull Contact ‑ Pay‑To Last Name for Electronic Paymentsbull Contact ‑ Pay‑To First Name for Electronic Paymentsbull Contact ‑ Pay‑To E‑mail Addressbull Contact ‑ Pay‑To Phone Numberbull Reports Contact ‑ Last Name (for reports if different than Contact ‑ Pay‑To Name)bull Reports Contact ‑ First Name (for reports if different than Contact ‑ Pay‑To Name)
If you are a new Blueprint practice after verification of the roster you may be required to sign contract amendments to include Blueprint within your standard contract In addition to the contract amendments you will be asked to complete an electronic funds transfer (EFT)direct deposit form to establish your account for receipt of the monthly PPPM payments
Blueprint Practice Payment Method based on VCHIPNCQA PCHM Score
Payment for newly‑scored practices will be effective on the first of the month after the date that the Blueprint transmits NCQA PPC‑PCMH scores from the Vermont Child Health Improvement Program (ldquoVCHIPrdquo) to the Payers and will initially be based on VCHIP scores Changes in payment due to the subsequent receipt of NCQA scores as well as for practices that are being re‑scored will occur on the first of the month after NCQA scores are received by Payers from the Blueprint
BCBSVT generates monthly PPPM payments There is a one month lag in the BCBSVT Blueprint payment cycle (ie for a PCMH effective October 1st first payment will be made in November)
BCBSVT will send the organization one provider payment for all the individual practice sites (identified by tax id) and an initial membership attribution report The report is in excel format and contains the following summary and data elements
96
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx
Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
If the vendor reporting has multiple practices within it each practicersquos PPPM payment is sub‑totaled and there will be a grand total of all practices at the bottom of the report
Reports are sent directly to the Reports Contact individual(s) identified on the PPPM Attribution Physician Practice Roster Reports are sent via secure e‑mail
If a PCMH wants to continue to receive a monthly attributed membership report after the initial reporting period as part of the payment cycle we ask that you make a request via e‑mail and send it to providerfilesbcbsvtcom
If you do not want to receive monthly but has a periodic need to have you can make a request at any time via e‑mail (at providerfilesbcbsvtcom) and we can provide you with a current membership report Following the receipt of the request the attributed membership report will be provided within 5 business days
Additionally BCBSVT will no longer be performing any special formatting of the reports on the practicersquos behalf as done in the past All reporting will be formatted the same and will continue to be provided in excel format
BCBSVT membership attribution criteria
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for Commercial Insurers and Medicaid located on the Blueprint website httpdvhavermontgovadvisory‑boardspayer‑implementation‑work‑group
Blueprint Practice membership reconciliation
BCBSVT provides an initial membership attribution snapshot report to the PCMH (or designee) in accordance with the Blueprint Manual (located here on the Blueprint website httpblueprintforhealthvermontgov
The Snapshot report contains the following summary and data elements
Tax ID xxxxxxxxx
Blueprint for Health Patient Centered Medical Home Hospital Service Area xxxx Paid Date xxxxxx Incurred Date xxxxxx Date xxxxxxxx Vendor Name xxxxxxxxx Total Dollar Amount $xxxxxx Total Number of Members are xxxx
97
If the vendor reporting has multiple practices within it each practicersquos monthly PPPM payment is sorted and sub‑totaled by vendor NPI A grand total for all practices is located at the top and bottom of the report
BCBSVT line of business (LOB) andor Employer Group exclusions for Blueprint payment
Note This is information is subject to change Please look for provider notificationsportal noticesbull Brattleboro Retreatbull CBA Bluebull Howard Center bull University of Vermont Medical Center Employer Group (prefixes FAH FAO and FAC)bull IBEW Utilitybull Inter‑Plan Programbull BlueCardbull New England Health Plan (NEHP)bull MedicompMedicare Supplemental (Medicare is primary)MediGapbull Some Administrative Service Only (ASO) Groups
BCBS members who reside in Vermont have the opportunity to participate in the Blueprint for Health program Those that do choose to participate will be included in reporting and payments To the extent you will be receiving Blueprint payments for BlueCard members these payments will retrospective monthly PMPM payments just like the payments for your practicersquos BCBSVT members While there is a one‑month lag in the Blueprint payment cycle for BCBSVT members there will e a three‑month lag in the Blueprint payment cycle for BlueCard members For example the March Blueprint payment would include any January BlueCard membership
Need help Identifying BCBSVTCBA BlueTVHPNEHP Members Click here httpwwwbcbsvtcomexportsitesBCBSVTproviderresourcesreferenceguidesIdentifying_BCBSVT_CBA_Blue_TVHP_NEHP_Memberspdf
Additional Blueprint Information Resources
Additional Blueprint InformationResources ‑ located on the Blueprint website httpblueprintforhealthvermontgov
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas
Attribution fees are paid during the three month grace period for individuals covered through the Exchange (prefix ZII) and are not recovered For full details on Grace Periods see ldquoGrace Period for Individuals Through the Exchangerdquo in section 6
Blueprint Executive Committeebull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
98
Blueprint Expansion Design and Evaluation Work Groupbull 2013 Meeting Schedulebull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull Executive Committee Members
Blueprint Payment Implementation Work Groupbull 2012 Meeting Schedulebull Minutes of Meetingsbull Agendas for Meetingsbull PPPM Atrribution Roster Templates (3142012)bull PPPM and CHT Payment Methodologies by Payer (1162012)bull Attribution Method and List of Codes ‑ Medicaid and Commercial
Insurers (152012)bull Attribution Method and List of Codes ‑ Medicare (1192011)bull Payment Implementation Work Group Members
Blueprint Payment Implementation Work Groupbull Under Construction
Note Informationresources are subject to change or new additions will be added so we encourage you to review this information periodically to ensure you are kept informed
Questions on the Blueprint program can be directed to your provider relations consultant at (888) 449‑0443
99
Section 9 NOTE The section of the provider manual can only be used for information on claims with a date of service on or prior to March 8 2018For information related to claims with a date of service March 9 2018 or after please refer to our on‑line provider handbook
The Federal Employee Program (FEP)Introduction
As a contracted providerfacility with BCBSVT you are eligible to render services to Federal Employee Program members who travel or live in Vermont
This section is designed to describe the advantages of the program while providing you with information to make filing claims easy
This section offers helpful information aboutbull Identifying membersbull Verifying eligibilitybull Obtaining pre‑certificationspre‑authorizationsbull Filing claimsbull Who to contact with questions
The Federal Employee Program (FEP)
FEP is a health care plan for government employees retirees and their dependents It provides hospital professional provider mental health substance abuse dental and major medical coverage of medically necessary services and supplies BCBSVT processes claims for FEP services rendered by Vermont providers in Vermont to FEP members Members with FEP coverage have ID numbers that begin with alpha prefix R
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit claims for members that receive services in the State of Vermont regardless of their residence BCBSVT is your point of contact for questions on services rendered in Vermont including eligibility benefits pre‑certification prior approval and claim status
Member ID Cards
When an FEP member arrives at your office or facility be sure to ask them for a current membership identification card
The main identifier for an FEP member is the alpha prefix of R The ID cards may also havebull ldquoPPOrdquo in a United States logo for eligible PPO membersbull ldquoBasicrdquo in a United States logo
Important facts concerning memberrsquos IDsbull A correct member ID number includes the alpha prefix R followed by 8 digits
As a provider servicing out‑of‑area members you may find the following tips helpfulbull 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 that you
have up‑to‑date information in your patientrsquos filebull Member IDs only generate in the subscriber namebull The back of the ID card will have the memberrsquos local plan information however if you are rendering the services in Vermont BCBSVT will be your point
of contact regardless of their planrsquos locationbull Make copies of the front and back of the memberrsquos ID card and pass the key information on to your billing staff
100
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 memberrsquos ID numbers
Sample ID Cards
The United States logo will appear on the top right on the front of card
Enrollment Code
Coverage and Eligibility Verification
SELF SELF amp FAMILY SELF PLUS ONE Standard Option (PPO) 104 105 106 Basic Option 111 112 113
Verifying eligibility and confirming the requirements of the memberrsquos policy before you provide services is essential to ensure complete accurate and timely claims processing There are two methods of verification available
Phone ‑ Call the Federal Employee Program customer service at (800) 328‑0365
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT reviewing and responding to ldquoAdvanced Benefit Determinationsrdquo This allows members and providers to submit a request in writing asking for benefit availability for specific services and receive a written response on coverage Refer to section 4 ‑ Advanced Benefit Determination for further information
Utilization Review
You should remind patients that they are responsible for obtaining pre‑certificationpreauthorization for specific required services When the length of an inpatient hospital stay extends past the previously approved length of stay any additional days must be approved Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials
To obtain approval for an extended stay Call the Federal Employee Program (800) 328‑0365 and ask to be transferred to the utilization review area Or contact the utilization review area directly at (800) 922‑8778
The BCBSVT plan may contact you directly for clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member
101
Claims Filing
Below is an example of how claims flow through the Federal Employee Program You should always submit claims to BCBSVT for services rendered in Vermont
1 Member of Federal Employee Program receives services from you the provider
2 Provider submits claim to the local Blue Plan
3 BCBSVT recognizes FEP member and adjudicates claim according to memberrsquos benefit plan and transmits claim payment disposition
4 BCBSVT plan issues a Summary of Health Plan to the member and a Remittance advice to you the provider
5 You (the provider) should follow up with member on appropriate out‑of‑pocket costs if applicable according to your remittance advice
Following these helpful tips will improve your claim experiencebull Ask members for their current member ID card and regularly obtain new photocopies of it (front and back) Having the current card enables you to
submit claims with the approrpriate member information (including R alpha prefix) and avoid unnecessary claims payment delaysbull Check eligibility and benefits electronically at wwwbcbsvtcom or by calling (800) 328‑0365 Be sure to provider the memberrsquos R alpha prefixbull Submit all Blue claims to BCBSVT PO Box 186 Montpelier VT 05601 Be sure to include the memberrsquos complete identification number when you
submit the claim This includes the R alpha prefix Submit claims with only valid alpha‑prefixes claims with incorrect or missing alpha prefixes or member identification numbers cannot be processed
bull In cases where there is more than one payer and a Blue Cross andor Blue Shield Plan is a primary payer submit Other Party Liability (OPL) information with the Blue Cross andor Blue claim
bull Do not send duplicate claims Sending another claim or having your billing agency resubmit claims automatically actually slows down the claims payment process and creates confusion for the member
bull Check claims status by contacting the Federal Employee Program at (800) 328‑0365bull Submit an electronic transaction via the Blue Exchange tool on wwwbcbsvtcom
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payer submit claims to your local Medicare intermediary
After you receive the Remittance Advice (RA) from Medicare attach a copy to the claim and submit on paper to BCBSVT for processing
The FEP Program for BCBSVT is not currently set up as an automatic cross over plan
You can make status inquiries for secondary claims through BCBSVT
Medical Records
There are times when BCBSVT will require medical records to review a claim These requests will come directly from BCBSVT Forward all requested medical records to BCBSVT including the cover sheet that was provided in the request Questions or inquiries regarding medical records need to be directed to the Medical Services Department at (800) 922‑8778 Do not send medical records with a claim unless requested by BCBSVT Unsolicited claim attachments may cause claim payment delays
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive full benefits and prevent double payment for services when a member has coverage from two or more sources The memberrsquos contract language explains which entity has primary responsibility for payment and which entity has secondary responsibility for payment if you discover the member is covered by more than one health plan and
bull BCBSVT or any other carrier is the primary payer submit the other carrierrsquos name and address with the claim to BCBSVTbull Other non‑Blue health plan is primary and BCBSVT or any other Blue Plan is secondary submit the claim to BCBSVT only after receiving payment from
the primary payer including the explanation of payment from the primary carrier
102
If you do not include the COB information with the claim it will result in having to investigate the claim This investigation could delay your payment or result in a post‑payment adjustment which would also increase your volume of bookkeeping
Dental Services
The FEP medical benefit coverage provides benefits for select procedures that are identified under the Schedule of Dental Allowance and Maximum Allowance Charges (MAC) Members also have the opportunity to purchase a dental supplement The supplement is called FEP BlueDental
Members who have opted to purchase the FEP BlueDental supplement will have a separate identification card It is important to request the member supply both ID cards at the time of the visit (FEP BCBSVT and FEP BlueDental) Make copies of both of the cards to keep on file
The FEP medical dental network consists of providers who have contracted directly with BCBSVT The contract you hold with BCBSVT does not include the FEP BlueDental network
The FEP BlueDental network (for Vermont) consists of providers who have contracted through CBA Blue The Blue Cross and Blue Shield of Vermont (BCBSVT) FEP contract you hold will not make you eligible to receive benefits or be a network provider for the FEP BlueDental network
Claims need to be submitted to the FEP program associated with the memberrsquos medical benefit coverage first for consideration of benefits For example if you rendered the services in Vermont you submit to BCBSVT If the services you rendered were in New Hampshire you submit to Anthem BCBS Once the claims have processed through the medical benefits coverage portion (you will receive your normal remittance advice) if appropriate the claim will be forwarded on to the FEP BlueDental network for processing You will receive the results of that processing directly from the FEP BlueDental
Glossary of Federal Employee Program Terms
Alpha Prefix R character preceding the subscriber identification number on the ID cards The alpha prefix identifies the Federal Employee Program and is required for routing claims
wwwbcbsvtcomprovider Blue Cross and Blue Shield Associationrsquos website which contains useful information for providers
Doctor amp Hospital Finder website httpproviderbcbscom A website you can use to locate health care providers in another BlueCross andor Blue Shield Planrsquos area This is useful when you need to refer the patient to a physician or health care facility in another location If you find that any information about you as a provider is incorrect on the website please contact BCBSVT
Enrollees (members) All Federal Employees Tribal Employees and annuitants who are eligible to enroll in the Federal Employee Health Benefits Program
wwwfepblueorg Federal Employee Program website
103
IndexSymbols
AAccess Standards 14
Primary Care and OBGYN Services 14Specialty Care Services 15
After Hours Phone Coverage 13Anesthesia
Anesthesia Physical Status Modifiers 65Anesthesiologist Modifiers 64Dental Anesthesia 66Electronic billing of anesthesia 65Medical Direction 64Medical Supervision 65Medical Supervision by a Surgeon 65Paper billing of anesthesia 66
Availability of Network PractitionersNetwork Availability Standards 15Performance Goals 15
BBCBSVTTVHP Special Health Programs 43ndash45
Benefits 51Better Beginnings 51BlueHealth Solutions 51Diabetes EducationTraining 44Hospice 44Requirements 51
BCBSVT amp TVHP Telephone DirectoryContact Us 1Getting in Touch with BCBSVT and TVHP 1Secure Messaging 1
Better Beginnings 43Billing of Members
Covered Services 20Missed Appointments 20Non-Covered Services 20Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 20
BlueCard 2 78ndash92 93ndash97 98ndash101Ancillary Claim for BlueCard 62BlueCard Member Claim Appeal 20BlueCard Program Quick Tips 92Claim Filing 84Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89
Electronically 89Phone 89
Coordination of Benefits (COB) Claims 88Eligibility Verification 87How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87
Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans
Medicare Advantage HMO 86Medicare Advantage Medical Savings Account (MSA) 87Medicare Advantage PFFS 86Medicare Advantage POS 86Medicare Advantage PPO 86
Frequently Asked Questions 89Frequently Asked Questions
BlueCard Basics 89Claims 90Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
Electronic 90Phone 90
Glossary of BlueCard Program Terms 91Glossary of BlueCard Program Terms
Alpha Prefix 91BCBScom 91BlueCard Accessreg 91BlueCard Eligibilityreg 91BlueCard PPO 91BlueCard PPO Member 91BlueCard Worldwidereg 91Coinsurance 91Consumer Directed Health CareHealth Plans (CDHC
CDHP) 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92How Does the BlueCard Program Work 79How to Identify Members 79Alpha Prefix 79Consumer Directed Health Care and Health Care Debit
Cards 81Coverage and Eligibility Verification 83
Electronic 83Phone 83
Helpful Tips 83Member ID Cards 79Sample combined Health Care Debit Card and Member ID
Card 82Sample Foreign ID Cards 81Sample stand-alone Health Care Debit Card 82
104
Utilization Review 84Introduction 78 93 98What is the BlueCard Program 78 93 98Accounts Exempt from the BlueCard Program 78Advantages to Providers 78Definition 78
Blue Cross and Blue Shield of VermontBlueprint Program 93Additional Blueprint Information Resources 96BCBSVT line of business (LOB) andor Employer Group
exclusions for Blueprint payment 96BCBSVT required Participating Practice DemographicPay-
ment Information 93Blueprint Advisory Groups-Meeting Schedules Minutes
AgendasBlueprint Executive Committee 96Blueprint Expansion Design and Evaluation Work
Group 97Blueprint Payment Implementation Work Group 97
Blueprint Advisory Groups-Meeting Schedules Minutes Agendas 96
Implementation Materials 93Notifications and Staff Contact Information 93Overview 93Practice membership reconciliation 95Practice Payment Method based on VCHIPNCQA PCHM
Score 94Contact Us 1By Mail 1In Person 1On The Web 1Privacy Practices 21Website 22How to Review Coverage History on the Web 22
BlueHealth Solutions 45ndash46
CCBA Blue 2Claim Filing 84
Adjustments 88Appeals 88Calls from Members and Others with Claim Questions 89Claim Payment 88Claim Status Inquiry 89Coordination of Benefits (COB) Claims 88Eligibility Verification 87Example of how claims flow through BlueCard 84 94How Claims Flow through BlueCard 84How to recognize Medicare Advantage Members 87International Claims 88Medical Records 88Medicare Advantage Claims Submission 87Medicare Advantage Overview 85 95Providers in a Border County or Having Multiple Con-
tracts 88Traditional Medicare-Related Claims 87Types of Medicare Advantage Plans 86 95
Claim ReviewBCBSVT Provider Claim Review 57
ClaimsAttachments 54Negative Balances 51Accounting for Negative Balances 51Specific Guidelines 59Submission 53
Claim Specific Guidelines 59ndash60 66ndash68Acupuncture 59Allergy 62 66Ambulance Air 59 60Ambulance Land 62Ancillary Claim for BlueCard 62Anesthesia 62 63Anesthesiologist Modifiers 64Bilateral Procedures 66Biomechanical Exam 66BlueCard Claims 66Breast Pumps 66Computer Assisted SurgeryNavigation 66Dental Anesthesia 66Dental Care 67Diagnosis Codes 67Diagnostic Imaging Procedures 67Drugs Dispensed or Administered by a Provider (other than
pharmacy 68Durable Medical Equipment 68Evaluation and Management reminder 68Current Procedural Terminology (CPT) 68Flu Vaccine and Administration 69Habilitative Services 69Home Births 69Home Infusion Therapy (HIT) Drug Services 69Hospital Acquired Condition 69 See Never Events and Hos-
pital Acquired ConditionsHub and Spoke System for Opioid Addiction Treatment
(Pilot Program) 69Immunization Administration 70Incident To 71Inpatient Hospital Room and Board Routine Services Sup-
plies and Equipment 71Laboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71Mammogram 71Mammogram (screening) and screening additional views 71Maternity (Global) Obstetric Package 72Medically Unlikely Edits 72Mental HealthSubstance Abuse Clinicians 72Mental HealthSubstance Abuse Trainee 72Modifiers 72National Drug Code (NDC) 73Never Events and Hospital Acquired Conditions 74Not elsewhere classified (NEC 74Not otherwise classified (NOS 74Observation Services 74 75Occupational Therapy Assistant (OTA) 74Physical Therapy Assistant (PTA) 74Place of Service 74 75Pre-Operative and Post-Operative Guidelines 74 75
105
Pricing for Inpatient Claims 75Provider-Based Billing 75Psychiatric Mental Health Nurse PractitionerPsychiatric
Clinical Nurse Specialist Trainee 75Robotic amp Computer Assisted SurgeryNavigation 75ldquoSrdquo Codes 75Specialty Pharmacy Claims 75State Supplied VaccineToxoid 75Subsequent Hospital Care 75Substance AbuseMental Health Clinicians 75Supervised Billing 75Supplies 76Surgical Assistant 76Surgical Trays 76Telemedicine 76Unit Designations 76Urgent Care Clinic 77Vision Services 77
Claim Status 56Corrected Claim 57Corrected Claims for Exchange Members within their grace
period 57Remittance Advice Discount of Charge Reporting 56Resubmission of Returned Claims 57
Claim Submission and Re-submission Information 53ndash59CMS 1500 Claims Form Instructions 56Coordination of Benefits (COB) 54Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54How to Avoid Paper Claim Processing Delays 54Important Reminders Regarding Submission of the HCFA
1500 56Medicare Supplemental and Secondary Claim Submission 55Paper Claim Submission 54Paper Remittance Advice 56
CMS 1500 Claim Form InstructionsImportant Reminders Regarding Submission of
the CMS 1500 56Complaint and Grievance Process
BlueCard Member Claim Appeal 20Level 1mdashA First Level Provider-on-Behalf-of-Member Ap-
peal 19Level 2mdashVoluntary Second Level Appeal (not applicable to
non group) 19Level 3mdashIndependent External Appeal 20Provider-on-Behalf-of-Member Appeal Process 19When a Member Has to Pay 20
ComprehensiveIndemnity (Fee-for-Service) 2
Contracting 4Coordination of Benefits (COB)
Medicare Supplemental and Secondary Claim SubmissionQuick Tips 55Special Billing Instructions for Rural Health Center or Feder-
ally Qualified Health Center 55Co-payment 52
Co-payments and Health Care Debit Cards 51Waiver of Co-payment or Deductible 52When to Collect a Co-payment
High Dollar Imaging 52Member Responsibility for Co-payment 53Mental Health and Substance Abuse 52Physicianrsquos Office
Preventive Care 53Where to Find Co-payment Information 51
Credentialing 6Facility Credentialing 9Policy 8Providers Currently Affiliated with CAQH 7Providers rights during the credentialing process 8Providers Without Internet Access 7
DDeductible
Waiver of Co-payment or Deductible 52Diabetes EducationTraining 44Durable Medical Equipment (DME) 68
Ancillary Claim for BlueCard 62
EEnrollment of Providers 6
Enrollment 6Enrollment of Locum Tenens 6Med Advantage 7Provider Credentialing 6Providers Currently Affiliated with CAQH 7Providers Not Yet Affiliated with CAQH 7Provider Listing in Member Directories 8Providers Without Internet Access 7
Evaluation and Management reminder 66 68
FFederal Employee Program (FEP) 2
Advanced Benefit Determinations 11 99Advantages to Providers 98Claims Filing 100Coordination of Benefits (COB) Claims 100Coverage and Eligibility Verification 99Dental Services 101Doctor amp Hospital Finder website 101Enrollees (members) 101Glossary of Terms 101Alpha Prefix 101Introduction 98Medical Records 100Member ID Cards 98Remember 99Services where Medicare is primary but provider (1) does
not participateaccept assignment and (2) is contracted with BCBSVT 12
Traditional Medicare-Related Claims when FEP is second-ary 100
Utilization Review 99Website 101
Fee-for-Service 2Frequently Asked Questions 89
BlueCard Basics 89Claims 90Where and how do I submit claims 90
106
Identifying Members and ID Cards 89Utilization Review 90Verifying Eligibility and Coverage 90
GGeneral Claim Information 48ndash50
Accounting for Negative Balances 51Balance Billing Reminders 48Covered Services 48Non-Covered Services 48Reimbursement 48BCBSVT Provider Claim Review 57Claim Filing Limits 48Adjustments 48Claim submission when contracting with more than one Blue
Plan 48New Claims 48Claims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Co-payments and HealthCare Debit Cards 51Corrected Claim 57Electronic Data Interchange (EDI) Claims 53General EDI Claim Submission Information 54Grace Period for Individuals through the Exchange 48 49How to use a Healthcare Debit Card 52Industry Standard Codes 48Interest Payments 51Member Responsibility for Co-payment 53Paper Claim Submission 54Attachments 54How to Avoid Paper Claim Processing Delays 54Physicianrsquos Office 52Resubmission of Returned Claims 57Take Back of Claim Payments amp Overpayment Adjustment
Procedures 48 50Use of Third Party BillersVendors 48Where to Find Co-payment Information 51
Glossary of BlueCard Program Terms 91ndash92Alpha Prefix 91bcbscom 91BlueCard Access 91BlueCard Eligibility 91BlueCard PPO 91BlueCard PPO Member 91Coinsurance 91Consumer Directed Health CareHealth Plans 91Coordination of Benefits (COB) 92Co-payment 92Deductible 92Hold Harmless 92Medicare Crossover 92Medicare Supplemental (Medigap) 92National Account 92Other Party Liability (OPL) 92Plan 92
Grace PeriodsClaims for dates of service during the first month of grace
period 49Claims for dates of service during the second and third
month of the grace period 49Grace Period for Individuals through the Exchange 48
HHealth Care Debit Cards
Co-payments and Health Care Debit Cards 51Health Care Deibt Cards
How to Use a Health Care Debit Card 52Health Insurance Portability and Accountability Act
(HIPAA) 20ndash21Business Associates 21Disclosure of Protected Health Information 20Member Rights and Responsibilities 21Standard Transactions 21
High Dollar ImagingMental Health and Substance Abuse 52
Home Infusion Therapy (HIT) Drug Services 69Hospice
Benefits 44BlueHealth Solutions 45Requirements 44
Hospital Acquired Condition 69
IIndemnity (Fee-for-Service) 2
Comprehensive 2Vermont Freedom Plan (VFP) 2
J
K
LLaboratory Handling 71Laboratory Services (self-ordered by patient) 71Locum Tenens 71
MMammogram 71Maternity 71Medically Unlikely Edits 72Medical Utilization Management (Care Management)
Advanced Benefit Determination 36Clinical Practice Guidelines 35Clinical Review Criteria 35Prior ApprovalReferral Authorization 36Retrospective review of prior approvals and referral authori-
zations 38Retrospective Reviews of Prior Approval Misquotes 39Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Medicare
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Member Certificate Exclusions 27Member Confidential Communications
107
ClaimCheck 58ClaimCheck Logic Review 59Exceptions to ClaimCheck Logic 58Inclusive Procedures 58Mutually Exclusive 58Standard Confidential Communication 28Unbundling 58
Member Identification CardsBlue Card 29 80Indemnity (Fee-for-Service) 29The Vermont Health Plan (TVHP) 30University of Vermont Open Access Plan 30Vermont Blue 65 (formerly known as Medi-Comp) 30Vermont Freedom Plan PPO (VFP) 30Vermont Health Partnership (VHP) 30
Member Proof of InsuranceCertification of Health Plan Coverage 31If your coverage has ended and you wish to get new cover-
age 32PHARMACY DETAILS 31
Member Rights and Responsibilities 21Mental Health and Substance Abuse 53Modifiers
Modifiers for Anesthesia 73
NNegative Balances
Accounting for 51Network Provider
Definition of 5Primary Care Provider (PCP) 5Specialty Care Provider (SPC) 5The Vermont Health Plan Contract 4
Never Events and Hospital Acquired Conditions 74New England Health Plan (NEHP) 2Notification of Change In Provider andor Group Informa-
tion 17ndash19Adding a Provider to a Group Vendor 18DeletingTerminating a Provider 18Provider Going on Sabbatical 18
OOBGYN Services
Primary Care and OBGYN Services 14Occupational Therapy
Occupational Therapy Assistant (OTA) 74Office Training and Orientation 4OpeningClosing of Primary Care Physician Patient Panels 15
Closing of an Open Physician Panel 15Opening of a Closed Physician Panel 15PCPs with closed patient panels 15Primary Care Services 15
PPaper Remittance Advice 56ndash57Participation 4
Incentives for Participation 5Indemnity (fee-for-service)Vermont Health Partnership 4The Vermont Health Plan Contract 4
PCP Initiated Member Transfer 16
Pediatric PatientsTransitioning 16Encourage the patients to call BCBSVT 16Send a letter 16Talk with your patients 16
Physical TherapyPhysical Therapy Assistant (PTA) 74
Preferred Provider Organization (PPO)Indemnity (Fee-for-Service) 2
Pre-notification of AdmissionsEpisodic Case ManagementAuthorization of Services 41Provider Referrals to Case or Disease Management 41Rare Condition Program (BCBSVT partnership with Accor-
dant Health Services) 41Urgent Pre-Service Review 41
Primary Care Provider (PCP)Definition of Network Provider 5OpeningClosing of Primary Care Provider Patient Panels 15PCP Initiated Member Transfer 16Primary Care and OBGYN Services 14
Prior ApprovalReferral Authorization 11Retrospective review of prior approvals and referral authori-
zations 38Special Notes Related to Prior Approval for Ambulance
Services 38Special Notes Related to Prior ApprovalReferral Authoriza-
tion 38Provider on Behalf of Member Appeal Process 19Providers
Change in Provider Information 17Credentialing 9Enrollment of 9Member Transfer 16Primary Care Provider (PCP)Coordination of Care 10Primary Care Provider Coordinates Care 10Roles and Responsibilities 9Accessibility of Services and Provider Administrative Service
Standards 13Access to Facilities and Maintenance of Records for Au-
dits 11Advanced Benefit Determinations 11After Hours Phone Coverage 13BCBSVT Audit 14Billing of Members 11
Covered Services 11Non-Covered Services 11
Compliance Monitoring 13Confidentiality and Accuracy of Member Records 11Conscientious Objections to the Provision of Services 9Continuity of Care 10Coordination of Care 10Follow-up and Self-care 9Missed Appointments 12Open Communication 9Primary Care Provider Coordinates Care 10Prior ApprovalReferral Authorization 11Provider Initiated Audit 14Reporting of Fraudulent Activity 14
108
Revised 01182019
Services where Medicare is primary but provider (1) does not participateaccept assignment and (2) is contracted with BCBSVT 12
Specialty Provider Responsibilities 10Waivers 13Selection Standards 45Specialty Care Provider (SPC)Continuity of Care 10Specialty Provider Responsibilities 10
Provider Selection Standards 45ndash47Confidentiality 47Medical and Treatment Record Standards 46Medical Record Review 46Office Site Review 47Performance Goals and Measurement 47Provider Appeal Rights 45Provider Appeals from Adverse Contract Action and Denials
of Participation in BCBSVT network 46Recredentialing Procedures 46Retrieval and Retention of Member Medical Records 47
QQuality Improvement Committees
Credentialing Committee 43Quality Improvement Project Teams 43Quality Oversight Committee 43Specialty Advisory Committee (SAC) 43
Quality Improvement (QI) ProgramClinical Guidelines 42HEDIS and Quality Data Gathering 42Medical Record Reviews amp Treatment Record Reviews 42Member Complaints 42Member Satisfaction Surveys 42Provider Feedback 43Quality Improvement Projects 42Quality Profiles 42Standards of Care 43
RReimbursement 9
Capitation 9Electronic Fund Transfer (EFT)direct deposit 9Fee for Service 9Paper Check 9
Remittance AdviceRemittance Advice Discount of Charge Reporting 56
Reporting of Fraudulent Activity 13Riders 3
SSpecialty Care Provider (SPC)
Definition of Network Provider 5Specialty Care Services 15
Submission and ReimbursementDiagnostic Imaging Procedures 67
TTaxpayer Identification Number 17The Vermont Health Plan (TVHP) 2
BlueCarereg 3
BlueCare Access 3BlueCare Options 3The Vermont Health Plan Contract 4
Transitioning Pediatric Patients 16
UUniversity of Vermont Openccess PlanSM 3Utilization Management Denial Notices Reviewer Availabil-
ity 18
VVermont Blue 65 Medicare Supplemental Insurance (formerly
Medi-Comp) 2Vermont Blue 65 (formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
WWaivers 13When to Collect a Co-payment
Claim (s) crossed over from Medicare that have a manifesta-tion ICD-10-CM codes as a primary diagnosis 55
High Dollar Imaging 52Mental Health and Substance Abuse 52Physicianrsquos Office 52Preventive Care 53
X
Y
Z
