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The Blue Book
SM
BlueMedicare HMO
BlueMedicare HMO
BlueMedicare PPO
BlueMedicare PPO
Supplemental Guide
BlueMedicare Rx
BlueMedicare Rx
BlueMedicare Supplement
BlueMedicare Supplement
Provider eManual
Offered by PARTNERS National Health Plans of North Carolina, Inc.
Offered by PARTNERS National Health Plans of North Carolina, Inc.
Offered by PARTNERS National Health Plans of North Carolina, Inc.
Offered by PARTNERS National Health Plans of North Carolina, Inc.
An independent licensee of the Blue Cross and Blue Shield Association. ®Mark of the Blue Cross and Blue Shield Association. SM Mark of Blue Cross and Blue Shield of North Carolina.
The Blue Book
SM
Provider eManual
Supplemental Guide
Edition: January 2015
Blue Cross and Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a
Medicare contract to provide HMO and PPO plans.
Note: In the event of any inconsistency between information
contained in this manual and the agreement(s) between you and
Blue Cross and Blue Shield of North Carolina (BCBSNC), the
terms of such agreement(s) shall govern. Also, please note that
BCBSNC may provide available information concerning an
individual’s status, eligibility for benefits, and/or level of benefits.
The receipt of such information shall in no event be deemed to
be a promise or guarantee of payment, nor shall the receipt of
such information be deemed to be a promise or guarantee of
eligibility of any such individual to receive benefits. Further,
presentation of Blue Medicare HMO and/or Blue Medicare
PPO identification cards in no way creates, nor serves to
verify an individual’s status or eligibility to receive benefits.
In addition, all payments are subject to the terms of the
contract under which the individual is eligible to receive
benefits. Member’s actual Blue Medicare eligibility and
benefits should always be verified in advance of
providing services.
SM
SM
To view pdf documents, you will need Adobe Acrobat Reader. If you do not have it already, a link is
provided for you at bcbsnc.com/providers/bluelinks/ or you can access the Web site for Adobe directly at
www.adobe.com/products/acrobat/readstep2.html.
Table of contents
1.
Introduction
1.1
About this manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1,2
1.2
Provider Manual – Blue Medicare HMOSM and Blue Medicare PPOSM
Supplemental Guide online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
1.3
Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
2. Contacting BCBSNC and general administration
2.1
Provider line 1-888-296-9790 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1
2.2
Written provider claim inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1
2.3
Online availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-2
2.4
BCBSNC central office telephone numbers and fax numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
2.5
AIM Specialty HealthSM (AIM) telephone and fax numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
2.6
Mailing addresses for BCBSNC Blue Medicare HMOSM and Blue Medicare PPOSM . . . . . . . . . . . . . 2-4
2.7
BCBSNC Network Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4
2.8
Changes to your office and/or billing information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4
3. Administrative policies and procedures
3.1
Participating provider responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
3.1.1 Basic principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
3.1.2 Criteria for selection and listing as a specialist or subspecialist . . . . . . . . . . . . . . . . . . . . . . 3-1
3.1.3 Primary care physician-patient relationship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2
3.1.4 Reimbursement and billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2,3
3.1.5 Self-pay for privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3
3.1.6 Utilization management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3
3.1.7 Quality Improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3
3.1.8 Use of physician extenders and assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-4
3.1.9 Advance directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-4
3.2
Special procedures to assess and treat enrollees with complex and serious medical conditions . . 3-4,5
3.3
Requirements for agreements with contracting and sub-contracting entities . . . . . . . . . . . . . . . . . 3-5
3.4
Requirements for provider credentialing and provider rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
3.5
Defines payments to contractors and sub-contractors as “federal funds,”
subject to applicable laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
3.6
Confidentiality and accuracy of medical records or other health and enrollment information
(including disclosure to enrollees and other authorized parties) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
3.7
Risk adjustment data validation program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5,6
3.8
Health Insurance Portability and Accountability Act (HIPAA) privacy regulation fact sheet . . . . . . . 3-6
3.9
Notification required upon discharge determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-6-8
3.10 Fast Track Appeals Process – Enrollee rights/provider responsibilities . . . . . . . . . . . . . . . . . . . . . 3-8,9
3.11 What do the SNF, HHA and CORF notification requirements mean for providers? . . . . . . . . . . 3-9-11
PAGE 1 of 8
Table of contents
3.12 More information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-11
3.13 Requirements to provide health services in a culturally competent manner . . . . . . . . . . . . . . . . . 3-11
3.14 Member input in provider treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-11
3.15 Termination of providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-11
3.16 Waiver of liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12
3.17 Reminder about opt-out provider status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12
4. Service area, ID cards, and provider verification of membership
4.1
Service area for Blue Medicare HMOSM and Blue Medicare PPOSM . . . . . . . . . . . . . . . . . . . . . . . . 4-1,2
4.2
Blue Medicare identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-3
4.3
Member identification card for Blue Medicare HMOSM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4
4.4
Member identification card for Blue Medicare PPOSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
4.5
Verification of membership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.6
Blue Medicare HMOSM plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-6
4.7
Blue Medicare PPOSM plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-7
4.8
Additional benefits for Blue Medicare members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8
4.8.1 Blue365® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8
4.8.2 PPO travel program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8
4.9
Medicare Advantage PPOSM network sharing for out-of-state
BlueCross and/or BlueShield members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8,9
4.9.1 How to recognize members from out-of-state Blue Plans participating in
MA PPO network sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9
4.9.2 Claims administration for out-of-area MA PPO Blue Plan members . . . . . . . . . . . . . . . . 4-9,10
4.9.3 Medicare Advantage PPOSM network sharing provider claim appeals. . . . . . . . . . . . . . . . . 4-10
5. Participating physician responsibilities
5.1
Participating physician responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.2
Mental health and substance abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.3
Advance directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.4
Physician case management services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.5
Physician availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-2
6. Quality Improvement Program
6.1
Quality Improvement overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1,2
6.2
Network quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-3
6.2.1 Access to care standards – primary care physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-3-5
6.2.2 Access to care standards – specialist (including non-MD specialist) . . . . . . . . . . . . . . . . . 6-5,6
6.2.3 Facility standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7,8
6.2.4 Medical record standards for primary care providers and OB/GYN providers . . . . . . . . 6-8-11
6.3
Clinical practice and preventive care guidelines overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-12-14
PAGE 2 of 8
Table of contents
7. Emergency care coverage
7.1
Emergency care coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.2
Urgently needed services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
8. Utilization management programs
8.1
Affirmation action statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.2
Pre-authorization review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.3
Inpatient review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.4
Medical case management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.5
Ambulatory review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1
8.6
Hospital observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1,2
8.7
Diagnostic imaging services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2
8.8
Medical Director’s responsibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2
8.9
New technology and new application of established technology review . . . . . . . . . . . . . . . . . . . . 8-2
8.10 Retrospective review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-2,3
8.11 Standard data elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-3
8.12 Disclosure of utilization management criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-3
8.13 Care coordination services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-4
8.14 Service determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-4
9. Prior authorization requirements
9.1
Prior authorization guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-1
9.2
Requesting durable medical equipment and home health services . . . . . . . . . . . . . . . . . . . . . . . 9-1,2
9.3
Prosthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-2
9.4
Power-operated vehicle/motorized wheelchair requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-3
9.4.1
Sample Medicare Advantage – Power Operated Vehicle (POV)/
motorized vehicle request form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-4
9.5
Diagnostic imaging management program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-5,6
9.6
Protocol for potential organ transplant coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-6
10. Pre-admission certification
10.1 Pre-admission certification guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1
10.1.1
Non-emergency pre-admission certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1
10.1.2
Emergency admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-2
11. Case management
11.1 Case management overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1
11.2 Case management programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1
11.2.1
Congestive Heart Failure (CHF) case management programs . . . . . . . . . . . . . . . . . . . . . 11-1
11.2.2
Chronic Obstructive Pulmonary Disease (COPD) case management programs . . . . . . 11-1,2
PAGE 3 of 8
Table of contents
11.2.3 Diabetes case management programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-2
11.2.4 Complex/chronic case management programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-2,3
11.3
Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-3
12. Medical guidelines
12.1
Medical guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-1
13. Claims billing and reimbursement
13.1
General filing requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-1
13.1.1 Requirements for professional CMS-1500 (02-12) Claim Form or other similar forms . . . 13-2
13.1.2 Requirements for institutional UB-04 Claim Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-3
13.2
Using the member’s ID for claims submission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-4
13.3
Electronic claims filing and acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-5
13.3.1 Sample electronic claims acknowledgement report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-6
13.4
Blue Medicare claims mailing addresses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-6
13.5
Claim filing time limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-7
13.6
Verifying claim status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-7
13.7
Electronic Funds Transfer (EFT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-7,8
13.8
Reimbursement for services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-8
13.8.1 Service edits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-8
13.9
Amounts billable to members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-8,9
13.9.1 Items for which providers cannot bill members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-9
13.9.2 Billing members for noncovered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-9
13.9.3 Hold harmless policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-9,10
13.9.3.1 CMS-required provisions regarding the protection of members eligible
for both Medicare and Medicaid “dual eligibles” . . . . . . . . . . . . . . . . . . . . . . 13-10
13.9.3.2 CMS-required provisions regarding the protection of members who
receive noncovered services or supplies from a participating provider . . . . . 13-10
13.10 Coordination of Benefits (COB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-9,11
13.11 Workers’ Compensation claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-11
13.12 Subrogation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-12
13.13 Claims reimbursement disputes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-12
13.14 Pricing policy for Part B procedure/service codes (applicable to all
PPO and HMO products) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-12,13
13.14.1 Prescription drug CPT and HCPCS codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-13
13.14.2 Policy on payment for remaining codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14
13.14.3 Policy on payment based on charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14
13.15 What is not covered under the medical benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-15-17
13.16 Using the correct NPI or BCBSNC assigned proprietary provider number for
reporting your health care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-17
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13.17 Using the correct Claim Form for reporting your health care services . . . . . . . . . . . . . . . . . . . . 13-18
13.17.1 CMS-1500 (02-12) Claim Form or other similar forms claim filing instructions . . . . 13-19-22
13.17.2 Sample CMS-1500 (02-12) Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-23
13.17.3 UB-04 claim filing instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-24-31
13.17.4 Sample UB-04 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-32
13.17.5 Policy on payment for remaining codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-33
13.18 HCPCS codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-33,34
13.19 ICD-9 and CPT codes for well exams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-34,35
13.20 Immunizations (Part D covered vaccines) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-35
13.20.1 Safe handling of vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-35
13.20.2 Medicare Part D vaccine manager for claims filing . . . . . . . . . . . . . . . . . . . . . . . . . 13-35,36
13.21 Allergy testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-36
13.22 Criteria for approving additional providers for allergy testing. . . . . . . . . . . . . . . . . . . . . . . . 13-36,37
13.23 Use of office or other outpatient service code 99211. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-37
13.24 Dispensing DME from the office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-37
13.25 Assistant surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-38
13.26 Ancillary billing and claims submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-38
13.27 Ancillary billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-38
13.27.1
Participating reference lab billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-38
13.27.2
Dialysis services billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-39
13.27.3
Skilled Nursing Facility (SNF) billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-39
13.27.4
Ambulatory Surgical Center (ASC) billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-39
13.27.5
Home Durable Medical Equipment (DME) and billing. . . . . . . . . . . . . . . . . . . . . . 13-40,41
13.27.6
Home Health (HH) billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-41,42
13.27.7
Home Infusion Therapy (HIT) billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-42,43
13.28 Hospital policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-43
13.29 Utilization management program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-44
13.30 UB-04 claims filing and billing coverage policies and procedures for BCBSNC. . . . . . . . . . . . . 13-45
13.30.1
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.2
Certified Registered Nurse Anesthetist (CRNA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.3
Autologous blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.4
Autopsy and morgue fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.5
Critical care units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.6
Diabetes education (inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-45
13.30.7
Dietary nutrition services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
13.30.8
EKG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
13.30.9
Hearing aid evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
13.30.10 Lab/blood bank services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
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13.30.11 Labor and delivery rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
13.30.12 Leave of absence days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46
13.30.13 Observation services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-46,47
13.30.14 Operating room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.15 Outpatient surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.16 Personal supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.17 Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.18 Recovery room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.19 Emergency room services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47
13.30.20 POA indicators required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-47,48
13.30.21 Room and board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-48
13.30.22 Special beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-48
13.30.23 Special monitoring equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-48
13.30.24 Speech therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-49
13.30.25 Take-home drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-49
13.30.26 Take-home supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-49
14. Pharmacy and specialty networks
14.1 The BCBSNC formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1
14.1.1
BCBSNC formulary medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1
14.1.2
Formulary changes/updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1
14.1.3
Generic substitution policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1
14.1.4
Prior authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1
14.1.5
Non-formulary requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-1,2
14.1.6
Quantity limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-2
14.1.7
Step therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-2
14.1.8
Drugs with Part B and D coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-2
14.1.9
Request for drugs to be added to the formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-2
14.1.10 Exceptions process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-2,3
14.1.11 Types of drugs not covered by prescription drug plan. . . . . . . . . . . . . . . . . . . . . . . . . . . 14-3
14.1.12 Medication therapy management program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-4
14.2 Medication management programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-4
14.2.1
High risk medications in the elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-4,5
14.2.2
Medication adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-5
14.3 Medical eye care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-5
14.4 Mental health/substance abuse management programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-5
14.5 Laboratory services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-5
14.6 BCBSNC office laboratory allowable list . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-6
PAGE 6 of 8
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15. Post-service provider appeals
15.1
Level I post-service provider appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-1
15.2
Level II post-service provider appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-1,2
15.2.1
Process for submitting a Level II post-service provider appeal . . . . . . . . . . . . . . . . . . . . 15-2
15.2.2
Level II post-service provider appeal for billing disputes . . . . . . . . . . . . . . . . . . . . . . . . . 15-2
15.2.3
Level II post-service provider appeal for medical necessity . . . . . . . . . . . . . . . . . . . . . 15-2,3
15.2.4
Filing fee matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-3
16. Member appeal and grievance procedures
16.1
Member complaints, grievances and appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1
16.2
What is an appeal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1
16.3
Who can file an appeal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1
16.4
How quickly does BCBSNC handle an appeal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1
16.5
What is a grievance?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-1
16.6
What involvement does a contracting physician have with an appeal? . . . . . . . . . . . . . . . . . . . . 16-2
17. Member rights and responsibilities
17.1
Member rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-1
17.2
Member responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-2
18. Sanction process
18.1
Grievance procedure/sanction process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-1
18.2
Provider notice of termination for recredentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-1
18.2.1
Level I appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-1
18.2.2
Level II appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-1,2
19. Credentialing
19.1
Credentialing/recredentialing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-1
19.2
Requirements for provider credentialing and provider rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-1
19.3
Policy for practitioners pending credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-2
19.3.1
19.4
Credentialing process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-2
Credentialing grievance procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-2
19.4.1
Provider notice of termination for recredentialing (Level I appeal) . . . . . . . . . . . . . . . . . 19-3
19.4.2
Level II appeal (formal hearing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-3,4
20. Marketing, advertising and brand regulations
20.1
Marketing and advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-1
20.2
Logo usage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-1
20.3
Approvals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-1
20.3.1
Sample Blue Medicare HMOSM and Blue Medicare PPOSM logos . . . . . . . . . . . . . . . . . . . 20-1
PAGE 7 of 8
Table of contents
21. Health Insurance Portability and Accountability Act (HIPAA)
21.1 Electronic transactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-1
21.2 Code sets and identifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-1
21.3 Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-1
21.4 Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21-2
21.5 Additional HIPAA information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-2
22. Privacy and confidentiality
22.1 Our fundamental principles for protecting PHI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-1
22.2 Privacy regarding services or items paid out-of-pocket . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-2
23. Medicare Advantage and Part D Compliance
23.1 Medicare Advantage and Part D Compliance for participating providers and
their business affiliates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-1,2
24. Forms
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-1
Medicare Advantage – Power Operated Vehicle (POV)/Motorized Wheelchair Request Form . . . 24-2
Provider Inquiry Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-3
Level I Provider Appeal Form for Blue Medicare HMOSM and Blue Medicare PPOSM . . . . . . . . . . . 24-4
25. Glossary of terms
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-1-4
PAGE 8 of 8
Chapter 1
Introduction
Chapter 1
Introduction
1.1
About this manual
We are pleased to provide you with a newly updated
and comprehensive Blue BookSM Provider Manual –
Blue Medicare HMOSM and Blue Medicare PPOSM
Supplemental Guide, for providers participating in
the Blue Cross and Blue Shield of North Carolina
(BCBSNC) provider network. This manual has been
designed to make sure that you and your office staff
have the information necessary to effectively
understand and administer Blue Medicare HMOSM
and Blue Medicare PPOSM member health care
benefit plans.
BCBSNC is a Medicare Advantage organization with
a Medicare contract to provide HMO and PPO plans.
BCBSNC’s goal is that all BCBSNC members are
provided quality health care, including preventive
care, by an ample, accessible network of participating
providers. We want to work with all participating
BCBSNC providers and their staffs to reach that
goal. Each HMO member electing Blue Medicare
coverage must choose a primary care physician who
is responsible for coordinating his/her care. PPO
members are strongly encouraged to choose a
primary care physician. BCBSNC strives to offer our
members the advantages of a primary care physician
and access to a broad panel of qualified specialists,
hospitals, ambulatory care facilities and nonphysician providers.
BCBSNC offers several resources for providers and
their staff. Our Network Management staff is
responsible for providing ongoing support to
participating providers’ office staff and is available at
any time to answer questions and/or direct inquiries
to other BCBSNC departments. Our health care
services staff of experienced nurses work with
physician offices on a regular basis for precertification,
case management, utilization review and quality
improvement issues. BCBSNC customer services
representatives are available for general billing,
claims or benefit questions.
The Provider Line 1-888-296-9790 provides another
resource to help you and your staff to obtain
information that is important in managing your Blue
Medicare HMOSM and Blue Medicare PPOSM patient
population.
Additional provider information is available on the
BCBSNC Web site’s provider section. HealthTrio
Connect is an electronic format that is available to
providers to access information such as claims status
and verify member benefits (the BCBSNC system
Blue eSM may not be accessed for these purposes).
Also, our Medical Director is available if BCBSNC
physicians have medical or procedural questions.
When contacting Care Management & Operations
for a prior authorization, providers can request that
a nurse assist in coordinating a discussion with the
Medical Director as part of the review process. Our
goal is to be responsive to our participating
physicians as they serve Blue Medicare HMOSM and
Blue Medicare PPOSM members in their practices. We
believe that your participation in BCBSNC provider
network is integral to our success. Our commitment
is to work with our providers to continually improve
our medical care delivery system.
We would like to highlight several items that may be
of importance to you and the chapters in which to
find them:
• Phone numbers for contacting BCBSNC –
Chapter 2
• Health benefit plans and sample identification
cards – Chapter 4
• Prior authorization requirements – Chapter 9
• Information about the Medicare Advantage and
Part D Compliance programs at BCBSNC and
hotline numbers for reporting fraud, waste,
abuse, or ethics concerns – Chapter 23
As referenced in your participation agreement, this
provider manual supplemental guide is intended to
supplement the agreement between you and
BCBSNC. Nothing contained in this provider manual
supplemental guide is intended to amend, revoke,
contradict or otherwise alter the terms and conditions
of the participation agreement. If there is an
inconsistency between the information contained in
this manual and the participation agreement, the
terms of the participation agreement shall govern.
PAGE 1-1
Chapter 1
Introduction
If there is an inconsistency between the participation
agreement and the member certificate, the member
certificate shall govern.
All codes and information are current as of the
manual proofing date but could change based on
new publications and policy changes. Changes will
be communicated through but not limited to the
mail, emails, and the Web site bcbsnc.com/content/
providers/blue-medicare-providers/index.htm.
Note: To get BCBSNC’s latest news and information
affecting providers, join our email registry by visiting
us at bcbsnc.com.
Web site resource
This manual contains information providers need to
administer BCBSNC Blue Medicare HMOSM and Blue
Medicare PPOSM plans efficiently with regard to
claims and customer service issues.
If you experience any difficulty accessing or opening
The Blue BookSM from our Web site, please contact
Network Management (contact information is
available in Chapter 2 of this manual). Additionally,
if you cannot access the Web site please contact
Network Management to receive a copy of the
manual in another format.
Provider Manual – Blue Medicare
HMO and Blue Medicare PPO
Supplemental Guide online
SM
If you want to save a copy of the manual to your
computer’s desktop, open the manual for viewing
following the same instructions, and after you have
opened the manual to view, just select “File” from
your computers tool bar, and select the option to
“Save a Copy,” then decide where you want to keep
your updated edition of the provider manual
supplemental guide on your computer, and click on
the tab to save.
Important: Please note that providers are reminded
Please note that we will periodically update this
manual. The most current version will be available in
the “Providers” section of the BCBSNC Web site at
bcbsnc.com/content/providers/blue-medicareproviders/index.htm.
1.2
The process to view is easy, just click on The Blue
BookSM Provider Manual – Blue Medicare HMOSM and
Blue Medicare PPOSM Supplemental Guide hyperlink
and select the option to open, it’s that easy.
SM
The Blue BookSM Provider Manual Blue Medicare
HMOSM and Blue Medicare PPOSM Supplemental
Guide is maintained on the BCBSNC Web site for
providers at bcbsnc.com/content/providers/bluemedicare-providers/index.htm. The manual is
available to providers for download to their desktop
computers for easy and efficient access.
that this manual supplemental guide will be
periodically updated, and to receive accurate and
up-to-date information from the most current version,
providers are encouraged to always access the
provider manual in the “Providers” section of the
BCBSNC Web site at bcbsnc.com/content/
providers/blue-medicare-providers/index.htm.
1.3
Feedback
This manual is your main source of information on
how to administer BCBSNC Blue Medicare HMOSM
and Blue Medicare PPOSM plans. If you cannot find
the specific information that you need within the
manual, please utilize the following resources:
• Your health care businesses provider agreement
with BCBSNC
• The BCBSNC Web site bcbsnc.com/content/
providers/blue-medicare-providers/index.htm
• BCBSNC Provider Blue Line at 1-888-296-9790
• Your Network Management office as listed in
Chapter 2, Contacting BCBSNC and general
administration
• HIPAA companion guide located on the Web
site at bcbsnc.com/content/providers/bluemedicare-providers/index.htm
• BCBSNC formulary information on the Web site
at bcbsnc.com/content/providers/bluemedicare-providers/index.htm
PAGE 1-2
Chapter 2
Contacting BCBSNC and
general administration
Chapter 2
Contacting BCBSNC and general administration
2.1
Provider line – 1-888-296-9790
The provider line is available to assist providers with
the following information:
• Route inquiries to the appropriate representative
only when it is necessary to speak with a
representative.
2.2
Written provider claim inquiry
One alternative to the provider line for claims status
information is the provider claim inquiry form (see
Chapter 24, Forms). Providers may make copies of
the form from this manual and send to one (1) of the
addresses below. Use of this form will allow:
• Identify claims status for each claim when
providers file multiple claims for the same
patient for the same date of service.
• Reconsideration of paid or denied claim for
professional services that were billed on a
CMS-1500 Claim Form or other similar forms
• Provide information relevant to claims payment
such as coinsurance amounts, check numbers
and check dates.
• Request for review of incorrectly paid claim for
professional services that were billed on a
CMS-1500 Claim Form or other similar forms
• Provide eligibility information and benefit
information including effective and termination
dates of coverage, and deductibles met for
current and prior year.
• Request for information regarding denial of
services not included in member’s health
benefit plan
• Provide current and future primary care physician
assignment name and telephone number.
• Refund of overpayments
(Note: Different mailing address for refund of
overpayments; see below)
• Identify multiple members with the same date
of birth to make sure the information is provided
for the correct patient.
• Provide Network Management telephone number.
• Provide BCBSNC address information.
• Requests for status of filed claims
The completed provider claim inquiry should be
mailed to:
Blue Cross and Blue Shield of North Carolina
PO Box 17509
Winston-Salem, NC 27116
• Prior plan approval status – approved / denied /
currently in review / unable to locate request.
or the form may be faxed to 1-336-659-2962.
• Provide referral status
Refund of overpayments ONLY should be mailed to:
Before calling the provider line, have the following
information available:
• Patient’s identification number
Blue Cross and Blue Shield of North Carolina
PO Box 30048
Durham, NC 27702
• Patient’s date of birth (mm/dd/yyyy)
• Date of service (mm/dd/yyyy)
• Amount of charge ($0.00)
Note: HealthTrio Connect and the Provider Line are
the most accurate and up-to-date resources for
verifying claim status. HealthTrio Connect allows
providers to access eligibility and claim information
from the convenience of their computer screen and
is faster than making a phone call.
PAGE 2-1
Chapter 2
Contacting BCBSNC and general administration
2.3
Online availability
For questions regarding
HealthTrio Connect
Provider directory assistance
HIPAA companion
Provider education information
Visit bcbsnc.com/content/providers/blue-medicare-providers/
index.htm
Diagnostic imaging management
program
Blue e SM at blue-edi.bcbsnc.com to access AIM’s Web-based
application ProviderPortalSM
Formulary
Visit bcbsnc.com/content/providers/blue-medicare-providers/
index.htm
Contact us on the Web at bcbsnc.com/providers
To access information specific to
Blue Medicare HMOSM and Blue
Medicare PPO,SM visit us online at
bcbsnc.com/providers.
Tab to the “Provider Home Page” and
click on “Blue Medicare Providers”.
PAGE 2-2
Chapter 2
Contacting BCBSNC and general administration
2.4
BCBSNC central office telephone numbers and fax numbers
Services
Phone
Fax
General information/customer service
1-800-942-5695
1-336-659-2963
Provider information line
1-888-296-9790
1-336-659-2963
Customer service
1-888-310-4110
Case management
1-877-672-7647
Claims
1-888-296-9790
Authorizations
1-888-296-9790
1-336-794-1556
Care Management & Operations
(utilization review/precertification)
1-888-296-9790
1-336-794-1556
Discharge planning/concurrent review
1-888-296-9790
1-336-794-1555
Episodic care management
(i.e., SNF, HH, acute inpatient rehabilitation,
prosthetics, motorized wheelchair)
1-888-296-9790
1-336-659-2945
2.5
1-336-794-1546
AIM Specialty HealthSM (AIM) telephone and fax numbers
Services
Phone
Fax
Diagnostic imaging management program
1-866-455-8414
1-800-610-0050
PAGE 2-3
Chapter 2
Contacting BCBSNC and general administration
2.6
Mailing addresses for BCBSNC Blue Medicare HMOSM and Blue Medicare PPOSM
Main mailing address
Main mailing address
Blue Cross and Blue Shield of North Carolina
PO Box 17509
Winston-Salem, NC 27116-7509
Blue Cross and Blue Shield of North Carolina
5600 University Parkway
Winston-Salem, NC 27105-1312
Claims for Blue Medicare members should be submitted electronically (or by paper when necessary) to Blue
Cross and Blue Shield of North Carolina (BCBSNC). Claims sent in error for Blue Medicare HMOSM and Blue
Medicare PPOSM members (filed electronically or by mail) will be returned to the submitting provider, which will
result in delayed payments.
2.7
BCBSNC Network Management
The BCBSNC Network Management department is responsible for developing and supporting relationships
with physicians and other practitioners, acute care hospitals, specialty hospitals, ambulatory surgical facilities
and ancillary providers. Network Management staff are dedicated to serve as a liaison between you and
BCBSNC, and are available to assist your organization.
Please contact Network Management for contract issues, fee information and educational needs.
Address
Phone
Fax
BCBSNC Network Management
PO Box 2291
Durham, NC 27702-2291
1-800-777-1643
1-919-765-4349
Provider address changes:
1-336-794-8866
Network Management staff is available to assist you Monday through Friday, 8 a.m. - 5 p.m. EST.
2.8
Changes to your office and/or billing information
Contact Network Management by phone, mail or fax to request changes to office and/or billing information
(e.g., physical address, telephone number, etc.) by sending a written request signed by the physician or office/
billing manager to the address or fax number above. Changes may include the following:
• Name and address of where checks should be sent
• Name changes, mergers or consolidations
• Group affiliation
• Physical address
• Federal tax identification number (attach W9 form)
• National Provider Identifier (NPI)
PAGE 2-4
Chapter 3
Administrative
policies and procedures
Chapter 3
Administrative policies and procedures
Blue Medicare HMOSM and Blue Medicare PPOSM are
offered by Blue Cross and Blue Shield of North
Carolina, an HMO with a Medicare contract. BCBSNC
does not discriminate based on race, ethnicity,
national origin, religion, gender, age, mental or
physical disability, health status, claims experience,
medical history, genetic information, evidence of
insurability or demographic location as defined by
CMS. All qualified Medicare beneficiaries may apply.
Members must be entitled to Medicare Part A,
enrolled in Medicare Part B and reside in the CMS
approved service area. Some limitations and
restrictions may apply.
Typically, the following provider types that specialize
in primary medicine may serve as a PCP: family
practitioner, internist, gerontologist, general
practitioner, and pediatrician (for those under
eighteen [18] years of age). In some cases a specialist,
such as an OB/GYN or an oncologist, may serve as
a PCP.
BCBSNC specialists
BCBSNC specialists are expected to render high
quality care appropriate to the needs of BCBSNC
members requiring specialized treatment.
Dual eligibility
3.1
Participating provider
responsibilities
3.1.1 Basic principles
BCBSNC participating providers are responsible for
providing quality health care to our members
according to the standards of care of the community,
the medical profession and the various professional
organizations and certifying boards. BCBSNC has
certain policies and guidelines and frequently makes
decisions regarding coverage of services; however,
these are not intended to be treatment decisions
and do not obviate or supersede the responsibility
of the physician to provide quality care, acting in the
patient’s best interest, in each individual case.
All providers who agree to participate as BCBSNC
providers accept responsibility for the provision of
appropriate medical care according to BCBSNC
policies and guidelines, and in keeping with the
standards of care described in the previous
paragraph of this section.
BCBSNC Primary Care Physicians (PCP)
BCBSNC primary care physicians are responsible for
providing or arranging for all appropriate medical
services for BCBSNC members. BCBSNC relies on
primary care physicians to decide when specialist
care is necessary or when other services such as
medical equipment are indicated. To serve as a
member’s PCP, providers must be credentialed by
BCBSNC as a PCP.
If provider meets BCBSNC credentialing standards
for both a primary care physician and a specialist
physician with respect to BCBSNC members, the
provider may elect to designate him or her as both a
primary care physician and a specialist physician as
approved by BCBSNC. Contact Network
Management for details.
3.1.2 Criteria for selection and listing as a
specialist or subspecialist
In order to be selected and listed in BCBSNC
provider directory as a medical specialist or
subspecialist (excluding general practice), one (1) of
the following criteria must be met:
1. The applicant must be board-certified by a
certifying board of the American Medical
Association and/or the American Board of
Medical Specialties.
2. The applicant must be board-qualified for a
specialty or subspecialty as defined by the
appropriate certifying board for a period of
not more than three (3) years following
completion of training, unless otherwise
defined by the board.
3. The applicant must be board-qualified and
within a three (3) year period following
completion of board qualification.
or
4. The applicant presents special documentation
justifying listing as a specialist.
PAGE 3-1
Chapter 3
Administrative policies and procedures
3.1.3 Primary care physician-patient
relationship
The primary care physician-patient relationship for
BCBSNC members begins at the time the member
selects the physician to be his or her primary care
physician and coverage for medical services becomes
effective. From that time on, unless the relationship
is terminated, the physician is responsible for
providing necessary medical care, including
emergency care. This includes a member who is new
to a practice, even if the patient has not made
previous contact with that office.
Individual requirements for obtaining medical
records, initial physicals and/or other initial contacts
with the physician’s office may be instituted by a
physician but do not alter the responsibility for
providing services when the need arises.
If a physician chooses to terminate a physicianpatient relationship, either for cause or change in
the physician’s availability, BCBSNC must receive
sixty (60) days notice. The member must be given
thirty (30) days written notice by BCBSNC in order
to select another primary care physician. During the
thirty (30) day period following receipt of the notice
by the member from BCBSNC, the physician remains
responsible for emergency and/or urgent care for
the member. A copy of the termination notice
must be sent to BCBSNC Network Management
department.
Practice limitations
Provider agrees to give BCBSNC thirty (30) days
prior written notice regarding the limitations or
closing of its practice, or the practice of any
participating physician, to BCBSNC members.
Availability and coverage
Participating physicians, primary care and specialist,
should be available to their patients when needed.
When the physician’s office is closed, the members
should have a clear and readily available access
pathway for needed care. Usually this will be
through an answering service.
Coverage for members in the event of the physician’s
absence should be arranged with a BCBSNC
participating physician if possible. If coverage is
arranged with a nonparticipating physician, the
participating physician is responsible for insuring
that the covering physician agrees to provide
services to BCBSNC members according to
BCBSNC policies, accept BCBSNC compensation
according to BCBSNC fee schedule, and bill only
BCBSNC for covered services (i.e., patients to be
billed only for appropriate copayments or
coinsurance).
3.1.4 Reimbursement and billing
What the provider can collect
Participating providers agree to bill only BCBSNC
for all covered services for BCBSNC members,
collecting only appropriate copayments or
coinsurance from the member. BCBSNC members
are directly obligated only for the copayment/
coinsurance amounts indicated on their member
card (and in their certificate of coverage or
evidence of coverage), payment for noncovered
services for which BCBSNC has issued an
organization determination denying coverage, and
payment for services after the expiration date of the
member’s coverage. The provider should not collect
any deposits and does not have any other recourse
against a BCBSNC member for covered services.
In the event that the participating provider provides
services which are not covered by the Plan, he or
she will not seek any payment from the patient
other than the copayment/coinsurance amounts
indicated on the member card (and in their
certificate of coverage or evidence of coverage)
unless, prior to the provision of such noncovered
services, BCBSNC has issued an organization
determination to the patient denying coverage.
BCBSNC shall make the relevant terms and
conditions of each Plan reasonably available to
participating providers.
PAGE 3-2
Chapter 3
Administrative policies and procedures
Submission of claims
Claims should be submitted using CMS-1500 Claim
Form or other similar forms; or UB-04 form. To file
electronic claims submission, please refer to
Section 14.1, General filing requirements, for
information on how to get set up to file electronically.
The provider is responsible for proper submission of
claims for compensation of services rendered. The
guidelines in the current AMA CPT and HCPCS
code books and ICD-9-CM must be used for coding.
Selection of the procedure and evaluation and
management codes should be appropriate for the
specific service rendered as is documented in the
patient’s medical record.
3.1.5 Self-pay for privacy
See Chapter 22 of this manual for important
information regarding self-pay for privacy.
3.1.6 Utilization management
BCBSNC utilization management charter and
annual work plan are reviewed and approved by a
Physician Advisory Group comprised of participating
physicians, the associate Medical Director, the
director of health care services operations and
BCBSNC staff. The policy relative to a specific
procedure or precertification requirement may be
obtained by contacting BCBSNC Care Management
& Operations.
All of BCBSNC providers participate in BCBSNC
utilization management process by providing
appropriate medical care and complying with
BCBSNC administrative guidelines and required
provider activities. These include:
1. Prior authorization requirements for admissions
(Chapter 9) and certain procedures
(Chapter 10)
2. Prior authorization requirements for durable
medical equipment and certain pharmaceuticals
(Chapters 9 and 14)
3. Participation in BCBSNC case management
program when necessary (Chapter 11)
4. Requirements for providers to supply
adequate information to permit concurrent
review for hospital patients and for patients
in an inpatient level of care and medical
services.
3.1.7 Quality Improvement
BCBSNC relies on its participating physicians to
deliver medical care of high quality. BCBSNC is
required to document and demonstrate that medical
care provided for our members is of acceptable
quality.
BCBSNC Quality Improvement program monitors
potential quality of care events, patient complaints
about quality of care, and assesses performance in
certain areas periodically.
When necessary, a complaint or potential quality
problem is presented to the credentialing committee.
The decision of BCBSNC associate Medical Director
or credentialing committee may be any of the
following:
1. No action is necessary.
2. The single event may or may not indicate a
problem; the item is filed in the provider’s file
for reference and to detect trends, if present.
3. The medical care provided is below standard
and remedial action is indicated. Institution of
the sanction process, however, is not warranted.
4. The medical care provided is below standard
and warrants instituting the sanction process.
The provider involved would be notified of decisions
3 or 4; however, notification is not considered
necessary for 1 or 2.
All items reviewed are placed in the provider’s file
and made available to the credentials committee at
the time of recredentialing.
PAGE 3-3
Chapter 3
Administrative policies and procedures
3.1.8 Use of physician extenders
and assistants
BCBSNC understands and encourages the use of
physician assistants, nurse practitioners and other
nursing and specially trained personnel. The
physician and the extender are expected to comply
with all applicable statutes and regulations as
appropriate for the practice site. Claims filing
guidelines are determined by the terms of the
participating provider agreement with BCBSNC.
The Blue Medicare HMO and Blue Medicare PPO
certificates of coverage informs members of their
right to make health care decisions and to execute
advance directives. We urge members to become
informed about advance directives and then discuss
any questions or concerns they have about these
directives with their primary care physician.
Discussion of advance directives should be noted in
the member’s medical record. Additionally, BCBSNC
participating physicians are required to keep a copy
of an advance directive a member has written in
his/her medical record.
SM
SM
3.1.9 Advance directives
On December 1, 1991, the requirements for advance
directives in the Omnibus Budget Reconciliation Act
of 1990 “OBRA 1990” took effect. As of that date
Medicare and Medicaid certified hospitals and other
health care providers (such as prepaid health plans
[HMOs]) must provide all adult members with written
information about their rights under state law to
make health care decisions, including the right to
accept or refuse treatment and the right to exclude
advance directives.
Blue Cross and Blue Shield of North Carolina
recognizes the difficulty of making decisions about
the medical care of a loved one. The decision to
administer treatment of extraordinary means is an
issue with no easy answers, an issue which will elicit
a variety of responses from different people.
Thinking about these issues is difficult; however, a
member may wish to set out in advance what sort of
treatment he or she would like to receive under
serious medical conditions. It may be that a member
will become seriously ill or injured and unable to
make these decisions for themselves.
Considering and discussing his/her views on life
sustaining treatment when they are not under
pressure or strain may make the process somewhat
less difficult. The member may then wish to draft an
advance directive, which instructs his/her physician
regarding the types of treatment they want or do
not want under special, serious medical conditions.
Alternatively, they may wish to designate health care
power of attorney to an individual who will make
health care decisions should they become unable to
do so.
3.2
Special procedures to assess and
treat enrollees with complex and
serious medical conditions
As a managed care organization with a contract with
CMS, BCBSNC is required by the balanced budget
act to ensure identification of individuals with
complex and serious medical conditions, assessment
of those conditions, identification of medical
procedures to address and/or monitor the conditions
and development of plans appropriate to those
conditions. To meet this CMS requirement, BCBSNC
sends out an initial health risk assessment
questionnaire to new members at the time of
enrollment asking members to complete the
questionnaire. Member participation is voluntary.
The members mail the completed survey to
BCBSNC. The information in the survey is entered
into a database. If the sum of the results equal or
are greater than a designated score, the member is
flagged as potentially at risk for having, or
developing a complex and serious medical
condition. The member receives a letter indicating a
care manager will contact him or her for an
additional assessment.
Members identified as potentially at risk for having
or developing a complex and serious medical
condition will be further screened/assessed by their
PCP and/or care manager to determine if they have
a complex and serious medical condition.
PAGE 3-4
Chapter 3
Administrative policies and procedures
The PCP must develop a treatment plan including
an adequate number of visits to a contracting
specialist to accommodate the treatment plan.
Based on the results of the detailed assessment, the
care manager, in cooperation with the PCP or
managing physician identifies and documents
problems, provides interventions and coordinates
services that supports the member’s needs and the
physician’s treatment plan. This function is carried
out by BCBSNC care management staff or
designated vendor.
3.3
Requirements for agreements with
contracting and sub-contracting
entities
The current provider contracts outline provisions
which must be agreed to in order to provide services
to BCBSNC members. These provisions include
timeframes regarding record retention for inspection
purposes and other key rules a provider must realize
when dealing with a government-sponsored program.
Please refer to your contract for details.
3.4
Requirements for provider
credentialing and provider rights
BCBSNC follows a documented process governing
contracting and credentialing, does not discriminate
against any classes of health care professionals, and
has policies and procedures which govern the denial,
suspension and termination of provider contracts.
This includes requirements that providers meet
Original Medicare requirements for participation,
when applicable. Qualified providers must have a
Medicare provider number for participation. For
more information, refer to Chapter 19, Credentialing.
3.5
Defines payments to contractors
and sub-contractors as “federal
funds,” subject to applicable laws
BCBSNC follows a documented process governing
contracting and credentialing, does not discriminate
against any classes of health care professionals, and
has policies and procedures which govern the denial,
suspension and termination of provider contracts.
This includes requirements that providers meet
Original Medicare requirements for participation,
when applicable. Qualified providers must have a
Medicare provider number for participation. For
more information, refer to Chapter 19, Credentialing.
3.6
Confidentiality and accuracy of
medical records or other health and
enrollment information
(including disclosure to enrollees
and other authorized parties)
Providers are reminded that member identifiable
data should not be released to entities other than
BCBSNC or BCBSNC authorized representatives
without the consent of the member, except as
required by law. Further, providers are advised that
members have a right to access their own medical
records subject to reasonable guidelines developed
by providers.
3.7
Risk adjustment data validation
program
The Balance Budget Amendment (BBA) of 1997
mandates that CMS payments to Medicare
Advantage (MA) organizations are based on the
health status of each beneficiary. The new payment
methodology uses risk adjustment, which is
sometimes called case-mix adjustment, that
incorporates diagnoses from hospital inpatient,
hospital outpatient and physician services into
adjusted capitated payments made to MA
organizations.
Since the passage of the BBA, CMS has been moving
from a demographic based payment system to a risk
adjusted payment system. MA organizations will be
fully risk adjusted beginning in 2007. That means
that 100% of the MA’s capitation for each member
will be based on his or her relative health status.
Once the new payment methodology is fully
implemented, ensuring complete and accurate data
will be paramount to BCBSNC ability to maintain a
competitive presence in the Medicare Advantage
program.
PAGE 3-5
Chapter 3
Administrative policies and procedures
The BBA mandates that MA plans collect and submit
beneficiary level ICD-9 CM data to CMS. This data is
used to determine the health status of each
beneficiary. The capitation for each beneficiary is
then adjusted to reflect the dollars needed to care
for a beneficiary in a subsequent payment period.
CMS performs data validation to verify that the
diagnosis codes submitted by the Medicare
Advantage organization are supported by the
medical record documentation for an enrollee. Data
discrepancies may affect risk-adjusted payment. The
data validation process begins with the beneficiary
records supplied by the physician to the MA
organization. It is incumbent on physicians and their
office staff to ensure that the documentation is
complete and accurate in response to the validation
request by the MA organization. MA organizations
must attest to the completeness and accuracy of the
data submitted for risk adjustment.
BCBSNC is initiating a new program by which to
validate this data. The program may require on-site
medical record review. In some cases, the validation
can be handled via mail using questionnaires. Risk
adjustment does not require a change in the way
that claims are filed or reported. Any medical record
request made for risk adjusted payment validation is
allowed under HIPAA regulations.
3.8
Health Insurance Portability and
Accountability Act (HIPAA) privacy
regulation fact sheet
The collection of risk adjustment data and request
for medical records to validate payment made to
Medicare Advantage (MA) organizations does not
violate the privacy provisions of HIPAA. Therefore, a
patient authorized release of information is not
required to submit risk adjustment data or to
respond to a medical request from CMS for data
validation. Specific sections of the HIPAA privacy
regulation are referenced below:
General Reference:
45 Code of Federal Regulations (CFR) Part 164,
standards for privacy of individually identifiable
health information, final rule.
Web link:
www.ecfr.gov
www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/index.html?redirect=/Manuals/
www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/HospitalDischargeAppeal
Notices.html
CFR references:
42 CFR Subpart M, Sections 422.620 and 422.622.
Medicare Managed Care Manual, Chapter 13 Medicare Managed Care Beneficiary Grievances,
Organization Determinations, and Appeals
Applicable to Medicare Health Plans.
3.9
Notification required upon
discharge determination
If the Medicare health plan denies coverage of the
admission, this guidance does not apply. Instead the
plan must deliver the Notice of Denial of Medical
Coverage (or Payment) (NDMCP) with appeal rights.
42 CFR 422.620 and 422.622 require hospitals and
Medicare health plans to inform Medicare enrollees
who are hospital inpatients of their right to obtain
Quality Improvement Organization (QIO) review of
a discharge decision. These instructions delineate
the expectations of the enrollee (or their representative,
if applicable), responsibilities of hospitals,
responsibilities of Medicare Health plans, and the
role of the QIOs when the enrollee requests an
immediate review by a QIO of the discharge decision.
The term enrollee means either enrollee or
representative, when a representative needs to
act for an enrollee.
The term “hospital” is defined as any facility
providing care at the inpatient hospital level,
whether that care is short or long term, acute or nonacute, paid through a prospective payment system or
other reimbursement basis, limited to specialty care
or providing a broader spectrum of services. The
definition includes critical access hospitals, Swing
beds in hospitals are excluded, because they are
considered a lower level of care. Religious nonmedical health care institutions are also excluded.
PAGE 3-6
Chapter 3
Administrative policies and procedures
These rules apply to Medicare managed care
enrollees who are hospital inpatients. Hospital
outpatients who are receiving Part B services, such
as observation stays or in the emergency
department, do not receive these notices unless
they are subsequently admitted as an inpatient.
Medicare enrollees in hospital swing beds or custodial
care beds do not receive these notices when they
are receiving services at a lower level of care.
Discharge is defined as a formal release of an enrollee
from an inpatient hospital. This includes when the
enrollee is physically discharged from the hospital,
as well as, when the enrollee is discharged “on paper”
meaning that the enrollee remains in the hospital,
but at a lower level of care (for example, the enrollee
is moved to a swing bed or to custodial care).
Section 1866 (a)(1)(M) Delivery of Important Message
from Medicare, applies to each individual who is
entitled to benefits under Medicare Part A. No
matter where in the sequence of payers Medicare
falls, these requirements still apply.
Enrollees who are being transferred from one
inpatient hospital setting to another inpatient
setting, do not need to be provided with the follow
up copy of the notice prior to leaving the original
hospital since this is considered the same level of
care. Enrollees always have the right to refuse care
and may contact the QIO if they have a quality of
care issue. The receiving hospital must deliver the
Important Message from Medicare again.
When a Medicare enrollee is admitted for hospital
services that are never covered by Medicare, these
notice requirements do not apply.
Instead, BCBSNC Blue Medicare should deliver the
NDMCP letter guiding the enrollee through the
standard or expedited appeals process.
BCBSNC contracting hospitals are responsible for
issuing the Important Message from Medicare
About Your Rights (IM) for the Plan. The IM is a
statutorily required notice to explain the enrollee’s
rights as a hospital inpatient, including discharge
appeal rights. All time and delivery requirements
that apply to Original Medicare Enrollees receipt of
this notice and the “follow up” copy apply for plan
enrollees as well.
The notices are available at www.cms.gov/
Medicare/Medicare-General-Information/BNI/
HospitalDischargeAppealNotices.html
An enrollee who is a hospital inpatient has a right to
request an immediate review by the QIO when
BCBSNC and the hospital (acting directly or through
its utilization review committee), with physician
concurrence, determines that inpatient care is no
longer necessary. An enrollee who chooses to
exercise the right to an immediate review must
submit a request to the QIO that has an agreement
with the hospital where the enrollee is an inpatient.
In order to be considered timely, the request must
be made no later than midnight of the day of
discharge and may be in writing or by telephone.
The enrollee should be available to discuss the case
upon request by the QIO. The enrollee may, but is
not required to submit written evidence to be
considered by the QIO.
When the enrollee requests a review no later than
midnight of the day of discharge the enrollee is not
financially responsible for inpatient hospital services
(except applicable coinsurance and deductibles)
furnished before noon of the day after the date the
enrollee receives notification of the QIO decision.
Liability for further inpatient hospital services
depends on the QIO decision.
Unfavorable determinations
If the QIO notifies the enrollee that the QIO did not
agree with the enrollee, liability for continued
services begins at noon of the day after the QIO
notifies the enrollee that the QIO agreed with the
hospital’s discharge determination, or as otherwise
determined by the QIO.
Favorable determinations
If the QIO notifies the enrollee that the QIO agreed
with the enrollee, the enrollee is not financially
responsible for continued care (other than
applicable coinsurance and deductibles) until the
Medicare health plan and hospital once again
determine that the enrollee no longer requires
inpatient care, secure the concurrence of the
physician responsible for the enrollee’s care, and the
hospital notifies the enrollee with a follow up copy
of the IM.
PAGE 3-7
Chapter 3
Administrative policies and procedures
When the enrollee fails to make a timely request for
an immediate review and remains in the hospital, he
or she may request an expedited reconsideration by
BCBSNC Blue Medicare as described in Section
422.584, but the enrollee may be held responsible
for charges incurred after the day of discharge or as
otherwise stated by the plan. If the enrollee receives
a favorable reconsideration, the Medicare health
plan must continue covering the care and/or refund
the enrollee for any expenses the enrollee incurred,
minus applicable coinsurance and deductibles.
When the QIO notifies BCBSNC Blue Medicare that
an enrollee has requested an immediate review,
BCBSNC will coordinate with the hospital to deliver
a Detailed Notice of Discharge (the Detailed Notice)
to the enrollee as soon as possible but no later than
noon of the day after the QIO’s notification. The
plan will consult with the hospital to ensure the
language in the Detailed Notice adequately explains
to the enrollee why the services are no longer
reasonable and medically necessary or are otherwise
no longer covered. The hospital will deliver the
notice to the patient or their representative. BCBSNC
Blue Medicare is responsible for ensuring proper
execution and delivery of the Detailed Notice.
Upon notification by the QIO of the enrollee’s
request for an immediate review, BCBSNC and the
hospital are required to submit all information that
the QIO needs to make its determination, including
copies of the IM and the Detailed Notice, as soon as
possible, but no later than noon of the day after the
QIO notifies the hospital of the enrollee’s request.
BCBSNC is financially responsible for coverage of
services during the QIO review as provided for in
the rules.
3.10
Fast Track Appeals Process –
Enrollee rights/provider
responsibilities
Enrollees of Medicare Advantage (MA) plans have
the right to an expedited review by a Quality
Improvement Organization (QIO) when they disagree
with their MA plan’s decision that Medicare coverage
of their services from a Skilled Nursing Facility (SNF),
Home Health Agency (HHA) or Comprehensive
Outpatient Rehabilitation Facility (CORF) should
end. This right is similar to the longstanding right of
a Medicare beneficiary to request a QIO review of a
discharge from an inpatient hospital.
What is “Grijalva”?
“Grijalva” is Grijalva vs. Shalala, a class action
lawsuit that challenged the adequacy of the
Medicare managed care appeals process. The
plaintiffs claimed that beneficiaries in Medicare
managed care plans were not given adequate notice
and appeal rights when coverage of their health
care services was denied, reduced or terminated.
Following extended legal negotiations – and
significant changes to appeals procedures that
resolved many issues – CMS reached a settlement
agreement with plaintiffs and published a proposed
rule based on that agreement in January 2001, and
the final rule in April 2003.
Regulations
SNFs, HHAs and CORFs must provide an advance
notice of Medicare coverage termination to MA
enrollees no later than two (2) days before coverage
of their services will end. If the enrollee does not
agree that covered services should end, the enrollee
may request an expedited review of the case by the
QIO and the enrollee’s MA plan must furnish a
detailed notice explaining why services are no
longer necessary or covered. KEPRO is the QIO for
the state of North Carolina. The review process
generally will be completed within less than fortyeight (48) hours of the enrollee’s request for a review.
The SNF, HHA and CORF notification and appeal
requirements distribute responsibilities under the
new procedures among four (4) parties:
1) The Medicare Advantage organization
generally is responsible for determining the
discharge date and providing, upon request,
a detailed explanation of termination of
services. (In some cases, Medicare
Advantage organizations may choose to
delegate these responsibilities to their
contracting providers.)
PAGE 3-8
Chapter 3
Administrative policies and procedures
BCBSNC policy requires the provider to
issue the Notice of Medicare Non-Coverage
(NOMNC) with the required timeline when
services are scheduled to terminate or when
the Plan determines a discharge date.
2) The provider is responsible for delivering the
NOMNC to all enrollees no later than two (2)
days before their covered services end.
3) The patient/Medicare Advantage enrollee (or
authorized representative) is responsible for
acknowledging receipt of the NOMNC and
contacting the QIO (within the specified
timelines) if they wish to obtain an expedited
review.
4) The QIO is responsible for immediately
contacting the Medicare Advantage
organization and the provider if an enrollee
requests an expedited review and making a
decision on the case by no later than the day
Medicare coverage is predicted to end.
These new notice and appeal procedures went into
effect on January 1, 2004. You should be aware that
the Medicare law (Section 1869[b][1][F] of the Social
Security Act) established a parallel right to an
expedited review for “fee-for-service” Medicare
beneficiaries. CMS implemented the procedure
7-1-2005 for these beneficiaries.
For additional information on the fast track appeals
process review the following Web sites:
• www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/mc86c13.pdf
• www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/MAEDNotices.html
• www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM3949.pdf
Additionally, providers can go directly to the
BCBSNC Web site to review information related to
the Fast Track Appeals process. An online
presentation is available at bcbsnc.com/content/
providers/education-and-learning/fast_track_
appeals_education.htm.
3.11
What do the SNF, HHA and CORF
notification requirements mean for
providers?
Notice of Medicare
Non-Coverage (NOMNC)
The NOMNC (formerly referred to as the Important
Medicare Message of Non-Coverage) is a short,
straightforward notice that simply informs the
patient of the date that coverage of services is
going to end and describes what should be done if
the patient wishes to appeal the decision or needs
more information. CMS has developed a single,
standardized NOMNC that is designed to make
notice delivery as simple and burden-free as
possible for the provider.
The NOMNC essentially includes only two (2)
variable fields (i.e., patient name and last day of
coverage) that the provider will have to fill in.
Plan contact information is added to the last section
of the letter in the event the request for a Fast Track
Appeal is not met, the provider/member may
contact the Plan for an appeal through the Plan.
Plan contact information
Blue Medicare HMO or Blue Medicare PPO
Attn: Appeals and Grievances Unit
PO Box 17509
Winston Salem, North Carolina 27116-7509
SM
SM
Blue Cross and Blue Shield of North Carolina
Blue Medicare HMO or Blue Medicare PPO
SM
SM
Toll Free:
1-888-310-4110 for HMO members
1-877-494-7647 for PPO members
TTY/TDD: 1-888-451-9957
Fax: 1-888-375-8836
Attention: Appeals and Grievances Unit
PAGE 3-9
Chapter 3
Administrative policies and procedures
When to deliver the NOMNC
Importance of timing/need for flexibility
Based on the MA organization’s determination of
when services should end, the provider is
responsible for delivering the NOMNC no later than
two (2) days before the end of coverage. If services
are expected to be fewer than two (2) days, the
NOMNC should be delivered upon admission. If
there is more than a two (2) day span between
services (i.e., in the home health setting), the
NOMNC should be issued on the next to last time
services are furnished. CMS encourages providers to
work with MA organizations so that these notices
can be delivered as soon as the service termination
date is known. A provider need not agree with the
decision that covered services should end, but it still
has a responsibility under its Medicare provider
agreement to carry out this function.
Although the regulations and accompanying CMS
instructions do not require action by any of the four
(4) responsible parties until two (2) days before the
planned termination of covered services, CMS
emphasizes that whenever possible, it’s in everyone’s
best interest for an MA organization and its
providers to work together to make sure that the
advance termination notice is given to enrollees as
early as possible. Delivery of the NOMNC by the
provider as soon as it knows when the MA
organization will terminate coverage will allow the
patient more time to determine if they wish to
appeal. The sooner a patient contacts the QIO to
ask for a review, the more time the QIO has to
decide the case, meaning that a provider or MA
organization may have more time to provide
required information.
How to deliver the NOMNC
The provider must carry out “valid delivery” of the
NOMNC. This means that the member (or
authorized representative) must sign and date the
notice to acknowledge receipt. Authorized
representatives may be notified by telephone if
personal delivery is not immediately available. In
this case, the authorized representative must be
informed of the contents of the notice, the call must
be documented, and the notice must be mailed to
the representative.
Expedited review process
If the enrollee decides to appeal the end of
coverage, he or she must contact the QIO by no
later than noon of the day before services are to end
(as indicated in the NOMNC) to request a review.
The QIO will inform the MA organization and the
provider of the request for a review and the MA
organization is responsible for providing the QIO
and enrollee with a detailed explanation of
non-coverage (DENC) of why coverage is ending.
The MA organization may need to present
additional information needed for the QIO to make
a decision. Providers should cooperate with MA
organization requests for assistance in obtaining
needed information. Based on the expedited
timeframes, the QIO decision should take place by
close of business of the day coverage is to end.
CMS understands that challenges presented by this
new process and has tried to develop a process that
can accommodate the practical realities associated
with these appeals. With respect to weekends, for
example, many QIOs are closed on weekends
(except for purposes of receiving expedited review
requests), as are the administrative offices of MA
organizations and providers. Thus, to the extent
possible, providers should try to deliver termination
notices early enough in the week to minimize the
possibility of extended liability for weekend services
for either MA enrollees or MA organizations,
depending on the QIO’s decision.
Similarly, SNF providers may want to consider how
they can assist patients that wish to be discharged in
the evening or on weekends in the event they lose
their appeal and do not want to accumulate liability.
Tasks such as ensuring that arrangements for
follow-up care are in place, scheduling equipment
to be delivered (if needed), and writing orders or
instructions can be done in advance and, thus,
facilitate a faster and more simple discharge. We
strongly encourage providers to structure their
notice delivery and discharge patterns to make the
new process work as smoothly as possible.
PAGE 3-10
Chapter 3
Administrative policies and procedures
CMS recognizes that these new requirements will be
a challenge – at least at first – and that there may be
unforeseen complications that will need to be
resolved as the process evolves. CMS intends to
work together with all involved parties to identify
problems, publicize best practices and implement
needed changes.
3.12
More information
Further information on this process, including the
NOMNC and related instructions can be found on
the CMS Web site at www.cms.hhs.gov/
healthplans/appeals. (Also, see regulations at 42
CFR 422.624, 422.626 and 489.27 and Chapter 13
of the MA manual at this same Web site).
3.13
Requirements to provide health
services in a culturally competent
manner
Providers are reminded to provide services in a
manner that meets the member’s needs. Medicare
beneficiaries may have disabilities, language or
hearing impairments or other special needs.
BCBSNC has established TTY/TDD lines and other
systems to assist members in getting the benefits to
which they are entitled. Please contact our BCBSNC
customer service staff if you are presented with an
issue that requires special assistance so that we can
assist in connecting the member with community
services if such services are not available within
the Plan.
Additionally, in North Carolina, providers can locate
an interpreter to assist in communicating with
Spanish speaking patients through the Carolina
Association of Translators and Interpreters (CATI).
CATI is an association of working translators and
interpreters in North Carolina and South Carolina
and is a chapter of the American Translators
Association. CATI provides contact information of
translators and interpreters within North Carolina at
www.catiweb.org.
3.14
Member input in provider
treatment plan
Members have the right to participate with
providers in making decisions about their health
care. This includes the choice of receiving no
treatment. BCBSNC policy is to require providers to
include members and their input in the planning
and implementation of their care or, when the
member is unable to fully participate in all treatment
decisions related to their health care, have an
appropriate representative participate in the
development of treatment plan for said member, be
they parent, guardian, family members or other
conservator. This includes educating patients
regarding their unique health care needs, sharing
the findings of history and physical examinations,
and discussing with members the clinical treatment
options medically available, the risks associated with
treatment options or a recommended course of
treatment. BCBSNC and provider recognize that the
member has the right to choose the final course of
action, if any, without regard to plan coverage.
A choice of treatment must not be made without
prior consultation with the member as member
acceptance and understanding will facilitate
successful care outcomes. However, a
recommendation by a participating provider for
noncovered services does not mean that the
services are covered, but as an option may be
pursued by member at the member’s expense.
3.15
Termination of providers
In the case of terminations by BCBSNC or the
provider, BCBSNC must notify affected members
thirty (30) days before the termination is effective.
Thus, we request that providers adhere to
termination notice requirements in provider
contracts so that members can receive timely notice
of network changes.
PAGE 3-11
Chapter 3
Administrative policies and procedures
3.16
Waiver of liability
Original Medicare’s waiver of liability provision,
which stipulates that the provider must notify the
patient if services could be denied as medically
unnecessary, does not apply to BCBSNC members.
Under Original Medicare, if the waiver of liability is
signed by the patient, then the patient is liable for
charges. With Blue Medicare HMOSM and Blue
Medicare PPO,SM a waiver of liability is not valid. With
the exception of normal copayment/coinsurance
amounts, a provider cannot charge a BCBSNC
member for noncovered services unless the member
has received an organization determination from
BCBSNC denying coverage before the services are
rendered. Waivers of liability are not valid and are
not effective to make the member liable for the cost
of noncovered services.
3.17
Reminder about opt-out provider
status
BCBSNC cannot use federal funds to pay for
services by providers that opt out of the Original
Medicare program and enter into private contracts
with Medicare beneficiaries. If you are contemplating
this payment approach, please notify BCBSNC in
advance of sending your termination notice.
PAGE 3-12
Chapter 4
Service area, ID cards, and
provider verification of
membership
Chapter 4
Service area, ID cards, and provider verification of membership
4.1
Service area for Blue Medicare HMO and Blue Medicare PPO
SM
SM
Blue Medicare advantage plans are available to individuals eligible for Medicare Part A and enrolled in
Medicare Part B. Due to Federal regulations people with end-stage renal disease may not be eligible unless
they meet exception criteria.
Blue Medicare HMOSM is a Medicare Advantage plan that includes health care benefits with or without
prescription drug coverage in one plan.
Blue Medicare PPOSM is a preferred provider organization plan that offers health care benefits and prescription
coverage in one plan.
Blue Medicare HMOSM and Blue Medicare PPOSM plans are offered by Blue Cross and Blue Shield of North
Carolina (BCBSNC).
Blue Medicare employer group membership can be sold in all one hundred (100) North Carolina counties.
Individual plans are available only in select counties across North Carolina within the service area approved by
the Centers for Medicare & Medicaid Services (CMS).
PAGE 4-1
Chapter 4
Service area, ID cards, and provider verification of membership
Medicare beneficiaries must live in the following Blue Medicare service areas in order to enroll:
2015 Service Area Map
Alamance
Alexander
Alleghany
Anson
Ashe
Avery
Beaufort
Bertie
Bladen
Brunswick
Buncombe
Cabarrus
Caldwell
Carteret
Caswell
Catawba
Chatham
Chowan
Cleveland
Columbus
Cumberland
Davidson
Davie
Duplin
Durham
Edgecombe
Forsyth
Franklin
Gaston
Gates
Granville
Greene
Guilford
Halifax
Harnett
Haywood
Henderson
Hertford
Hoke
Hyde
Iredell
Johnston
Jones
Lee
Lincoln
Madison
Martin
McDowell
Mecklenburg
Mitchell
Montgomery
Nash
New Hanover
Northampton
Onslow
Orange
Pamlico
Pender
Perquimans
Person
Pitt
Polk
Randolph
Richmond
Robeson
Rockingham
Rowan
Sampson
Scotland
Stanly
Stokes
Surry
Transylvania
Tyrrell
Union
Vance
Washington
Wake
Warren
Washington
Watauga
Wayne
Wilkes
Wilson
Yadkin
Yancey
The service area listing is current as of the publication date of this manual. As the service area expands we will
provide updates, available on the web at bcbsnc.com.
PAGE 4-2
Chapter 4
Service area, ID cards, and provider verification of membership
4.2
Blue Medicare identification cards
Blue Medicare HMOSM and Blue Medicare PPOSM members have identification cards with a “Blue” look. These
cards have the Blue Cross and Blue Shield recognizable symbols. When arranging health care and/or
submitting claims for services provided to Blue Medicare HMOSM and Blue Medicare PPOSM members contact
BCBSNC at our Winston-Salem location instead of our Durham offices. It’s easy to distinguish if a claim or
question should be directed to BCBSNC at our Winston-Salem location with a quick look at a Blue Medicare
member’s identification card. Please see the sample card image below:
Blue Medicare name and
plan type (PPO or HMO)
Front of card
Alpha-prefixes
that are
unique to
Blue Medicare
members
Prefixes for
Blue Medicare
plans always
end in the
letter J
Enhanced
Member Name
JOHN DOE
Member ID
YPWJ1230567801
Plan (80840)
Group No
Card Issued
Rx BIN
Rx PCN
Rx Group
xxxxxxxxxx
011100
mm-dd-yyyy
015905
HMONC
NCPARTD
$xx
Office Visit
$xx
ER/Urgent Care
$xx/day
Inpat Hospital
$xx
MHCD Outpt
xx%
Supplies/DME
Contract # H3449 005
MEDICARE
ADVANTAGE
HMO
One quick glance at the front of the
card and you can easily recognize a
member as having Blue Medicare, a
BCBSNC health care coverage plan.
The upper right hand corner of the
card displays that it’s for a Blue
Medicare plan and which plan type a
member has enrolled. Just below
you’ll find an area shaded in blue that
highlights the plan as offered by
BCBSNC. Look to the card’s left and
you’ll see that a Blue Medicare
member’s ID includes an alpha-prefix.
Blue Medicare alpha-prefixes are
unique to Blue Medicare members
and always end with the letter J.
The following are unique alpha-prefixes that can help you to identify a Blue Medicare plan type – even when
you do not have the member’s identification card in hand.
YPWJ – Blue Medicare HMOSM
Back of card
YPFJ – Blue Medicare PPOSM
It’s easy to distinguish between
Blue Medicare HMOSM members BCBSNC
and Blue Medicare PPOSM
claims
members, just look at the
mailing
address
alpha-prefix at the beginning
of the member’s Blue Medicare
identification code. The alpha
prefix YPWJ lets you know that the
member’s coverage type is an HMO
plan, and if you see YPFJ, you’ll know
that the coverage type is PPO.
www.bcbsnc.com/member/
medicare
North Carolina Hospitals or
physicians file claims to:
PO Box 17509
Winston-Salem, NC 27116
Hospitals or physicians outside
of North Carolina, file your claims
to your local BlueCross and/or
BlueShield Plan.
Members: See your Evidence of Coverage
(EOC) for covered services.
Customer Service:
TTY/TDD:
Provider Line:
Mental Health/SA:
1-888-310-4110
1-888-451-9957
1-888-296-9790
1-800-266-6167
Members send
correspondence to:
Blue Medicare HMO
PO Box 17509
Winston-Salem, NC 27116
BCBSNC
provider
service line
and Blue
Medicare
contact
information
SM
An independent licensees of the
Blue Cross and Blue Shield Association.
The back of a Blue Medicare member’s identification card provides further information about arranging health
care services and claim submission with BCBSNC. The cards display BCBSNC claims mailing address and
telephone service lines.
PAGE 4-3
Chapter 4
Service area, ID cards, and provider verification of membership
4.3
SM
Member identification card for Blue Medicare HMO
All Blue Medicare HMOSM members will receive a member ID card when they are enrolled. Patients should be
asked to present their Blue Medicare HMOSM ID card at the time of their visit. You will find it helpful to make a
copy of both sides of the member ID card when it is presented by the member. Members should present this
card to receive services and not their traditional Medicare card.
Front of card
Blue Medicare
name and
plan type (PPO or
HMO)
Enhanced
Alpha-prefixes that are
unique to Blue Medicare
members
Prefixes for Blue Medicare
plans always end in the
letter J
Member Name
JOHN DOE
Member ID
YPWJ1230567801
Plan (80840)
Group No
Card Issued
Rx BIN
Rx PCN
Rx Group
xxxxxxxxxx
011100
mm-dd-yyyy
015905
HMONC
NCPARTD
$xx
Office Visit
$xx
ER/Urgent Care
$xx/day
Inpat Hospital
$xx
MHCD Outpt
xx%
Supplies/DME
Contract # H3449 005
MEDICARE
ADVANTAGE
HMO
Back of card
www.bcbsnc.com/member/
medicare
BCBSNC claims
mailing address
North Carolina Hospitals or
physicians file claims to:
PO Box 17509
Winston-Salem, NC 27116
Hospitals or physicians outside
of North Carolina, file your claims
to your local BlueCross and/or
BlueShield Plan.
Members: See your Evidence of Coverage
(EOC) for covered services.
Customer Service:
TTY/TDD:
Provider Line:
Mental Health/SA:
1-888-310-4110
1-888-451-9957
1-888-296-9790
1-800-266-6167
BCBSNC provider
service line and
Blue Medicare
contact information
Members send
correspondence to:
Blue Medicare HMO
PO Box 17509
Winston-Salem, NC 27116
SM
An independent licensees of the
Blue Cross and Blue Shield Association.
PAGE 4-4
Chapter 4
Service area, ID cards, and provider verification of membership
4.4
SM
Member identification card for Blue Medicare PPO
All Blue Medicare HMOSM members will receive a member ID card when they are enrolled. Patients should be
asked to present their Blue Medicare HMOSM ID card at the time of their visit. You will find it helpful to make a
copy of both sides of the member ID card when it is presented by the member. Members should present this
card to receive services and not their traditional Medicare card.
Front of card
Enhanced
Alpha-prefixes that are
unique to Blue Medicare
members
Prefixes for Blue Medicare
plans always end in the
letter J
Member Name
JOHN DOE
Member ID
YPFJ1234567801
Plan (80840)
Group No.
Card Issued
Rx BIN
Rx PCN
Rx Group
XXXXXXXXXX
022100
mm-dd-yyyy
015905
PPONC
NCPARTD
Blue Medicare
name and
plan type (PPO or
HMO)
$XX
Office Visit
$XX
ER/Urgent Care
$XX/day
Inpat Hospital
$XX
MHCD Outpt
XX%
Out of Network
Contract # H3404 001
MA
PPO
MEDICARE ADVANTAGE
Back of card
www.bcbsnc.com/member/
medicare
BCBSNC claims
mailing address
1-877-494-7647
1-888-451-9957
1-888-296-9790
1-800-266-6167
Medicare limiting charges
apply.
North Carolina Hospitals or
physicians file claims to:
PO Box 17509
Winston-Salem, NC 27116
Hospitals or physicians outside
of North Carolina, file your
claims to your local Blue Cross
and/or Blue Shield plan.
Customer Service:
TTY/TDD:
Provider Line:
Mental Health/SA:
Members: See your Evidence of Coverage
(EOC) for covered services.
An independent licensee of the
Blue Cross and Blue Shield Association.
BCBSNC provider
service line and
Blue Medicare
contact information
Members send
Correspondence to:
Blue Medicare PPO
PO Box 17509
Winston-Salem, NC 27116
SM
PAGE 4-5
Chapter 4
Service area, ID cards, and provider verification of membership
4.5
Verification of membership
Possession of a Blue Medicare member ID card
does not guarantee eligibility for benefits coverage
or payment. Providers should verify eligibility with
BCBSNC in advance of providing services.
Except in an emergency medical condition,
providers are required prior to rendering any
services to BCBSNC members, to request and
examine the member’s BCBSNC Blue Medicare
identification card. If a person representing himself
or herself as a Blue Medicare member lacks a Blue
Medicare HMOSM or Blue Medicare PPOSM
membership card, the provider shall contact
BCBSNC by telephone for verification before
denying such person provider services as a BCBSNC
member. In an emergency medical condition the
provider will follow these procedures as soon as
practical. In the event member is determined to be
ineligible for coverage due to retroactive enrollment
activity and/or incorrect information submitted to
BCBSNC by employer group, BCBSNC will not be
responsible for payment for services rendered and
provider may seek compensation from member.
Please refer to the formulary at myprime.com/
MyRx/MyPrime/MedicareD/formulary/BCBSNC/.
4.6
Blue Medicare HMOSM is a Medicare Advantage
plan that provides members care and services from
doctors and hospitals that are within the Plan’s
network. It provides Medicare Parts A and B
coverage, while keeping out-of-pocket costs lower.
It also includes:
• $0 monthly premium plan available1
• Health care benefits and Medicare prescription
drug coverage combined in one plan2
• No referral needed to see a specialist
• Predictable copayments and costs
• Prescriptions filled at participating pharmacies
throughout the state, including most of the
major chain pharmacies, or through our mail
order prescription program
• Additional savings with our Preferred Pharmacy
Network
• Additional savings with our Blue365® discount
program
Blue Medicare HMOSM has four (4) different plans:
Standard, Medical Only, Enhanced and Essential.
While each share similar features, there are
differences in the amounts paid for things such as
copayments and inpatient hospital stays. Plans are
available in selected counties.
Blue Medicare HMO plans
SM
This summary of benefits for Blue Medicare HMOSM
members is not a guarantee of benefits coverage.
Always verify member eligibility and benefits prior
to providing services.
2. A formulary applies for all plans that include Medicare
prescription drug coverage.
Blue Medicare HMO provides coverage for:
®1 Mark of Healthways, Inc.
SM
• Inpatient/outpatient services
• Skilled nursing facility care
• Home health care
1. Rate is for Blue Medicare HMO Medical-Only plan, 2015.
SM
®, SM Marks of the Blue Cross and Blue Shield Association.
Benefits, premium and/or copayment/coinsurance may change
on January 1 of each year. The benefit information provided
herein is a brief summary, but not a complete description of
available benefits. A member’s complete benefits should always
be verified in advance of providing service.
• Worldwide emergency medical care
• Ambulance and urgent care
• Preventive care
PAGE 4-6
Chapter 4
Service area, ID cards, and provider verification of membership
4.7
Blue Medicare PPO plans
SM
This summary of benefits for Blue Medicare PPOSM members is not a guarantee of benefits coverage.
Always verify member eligibility and benefits prior to providing services.
Blue Medicare PPOSM plans provide coverage for:
• Inpatient/outpatient services
• Skilled nursing facility care
• Home health care
• Worldwide emergency medical care
• Ambulance and urgent care
• Preventive care
Blue Medicare PPOSM is a Medicare Advantage plan where care and services from doctors and hospitals are in
the plan’s network, but also allows members to see doctors outside the network, usually at a higher cost. It
provides Medicare Parts A and B coverage, while keeping out-of-pocket costs lower.
It also includes:
• Health care benefits and Medicare prescription drug coverage combined in one plan1
• No referral needed to see a specialist
• Predictable copayments and costs
• Prescriptions filled at participating pharmacies throughout the state, including most of the major chain
pharmacies, or through our mail order prescription program
• Additional savings with our Preferred Pharmacy Network
• Additional savings with our Blue365® discount program
There are two (2) Blue Medicare PPOSM plans: Enhanced and Enhanced Freedom. While each cover the same
benefits, there are differences in the amount paid for out-of-network services, copayments and inpatient
hospital stays.
1. A formulary applies for all plans that include Medicare prescription drug coverage.
®, SM Marks of the Blue Cross and Blue Shield Association.
®1 Mark of Healthways, Inc.
Benefits, premium and/or copayment/coinsurance may change on January 1 of each year. The benefit information provided herein is a
brief summary, but not a complete description of available benefits. A member’s complete benefits should always be verified in
advance of providing service.
PAGE 4-7
Chapter 4
Service area, ID cards, and provider verification of membership
4.8
Additional benefits for Blue
Medicare members
4.8.1 Blue365®
Members save with exclusive member discounts
through Blue365®,.8 This program offers discounts to
Blue Medicare HMOSM and Blue Medicare PPOSM on
a variety of products and services that can help
members live a more healthy and active lifestyle –
all at no additional cost.
• Hearing aids
• Laser eye surgery
• Vision services
• Medical bracelets
• Healthy eating
• Gym memberships
• And more!
4.8.2 PPO travel program
Our Blue Medicare PPOSM Travel Program enables
Blue Medicare PPOSM members traveling in certain
states and Puerto Rico to use the networks of other
participating Blue Cross and/or Blue Shield Medicare
Advantage PPO plans. Please see Section 4.9 for
additional information.
MA
PPO
MEDICARE ADVANTAGE
4.9
Medicare Advantage PPO
network sharing for out-of-state
Blue Cross and/or Blue Shield
members
SM
Blue Medicare Advantage PPOSM Plans, including the
BCBSNC offered Blue Medicare PPOSM plan,
participate in reciprocal network sharing. This
network sharing allows all Blue Cross and/or Blue
Shield MA PPO members from another state to
obtain in-network benefits when traveling or living in
the service area of any other Blue MA PPO Plan, as
long as the member sees a contracted MA PPO
provider.
This means that as a provider participating in the
Blue Medicare PPOSM plan you can see MA PPO
members from out-of-state Blue Plans; Blue Cross
and/or Blue Shield Plans other than Blue Cross and
Blue Shield of North Carolina (BCBSNC) and these
members are eligible to receive their same innetwork level of benefits, just like when receiving
care from their Blue Plan’s in-network providers at
home.
MA PPO network sharing extends the same access
of care to MA PPO out-of-state Blue Plan members
when receiving care in North Carolina that’s available
to Blue Medicare PPOSM members, and claims for
services will be reimbursed in accordance with your
Blue Medicare PPOSM negotiated rate with Blue
Cross and Blue Shield of North Carolina (BCBSNC).
Providers who are not participating in the Blue
Medicare PPOSM plan are not eligible to see MA PPO
out-of-state Blue Plan members as “in-network”
.
Nonparticipating providers will receive the Medicare
allowed amount for covered services except for
urgent or emergency care. Urgent or emergency
care will be reimbursed at the member’s in-network
benefit level. All other services will be reimbursed at
the member’s out-of-network benefit (when out-ofnetwork benefits are available) for nonparticipating
providers.
PAGE 4-8
Chapter 4
Service area, ID cards, and provider verification of membership
Providers participating with Blue Cross and Blue
Shield of North Carolina (BCBSNC), who are already
servicing MA members enrolled in the Blue
Medicare PPOSM plan are required to provide
services to out-of-area Blue Plan eligible Medicare
Advantage PPOSM members seeking care within
North Carolina. The same contractual arrangements
apply to MA PPO out-of-area Blue Plan members as
with our local Blue Medicare PPOSM members.
Exception note: If your practice is currently full (or
becomes full) and is closed to all new Medicare
Advantage PPOSM members, you are not required to
provide services for MA PPO out-of-area Blue Plan
members.
4.9.1 How to recognize members from
out-of-state Blue Plans participating in
MA PPO network sharing
The “MA” in the suitcase logo on a member’s
identification card tells you that the card belongs to
a member who is eligible as part of the MA PPO
network sharing program. Members have been
asked not to show their standard Medicare ID card
when receiving services; instead, members should
provide their Blue Cross and/or Blue Shield member
identification cards.
MA
PPO
MEDICARE ADVANTAGE
Providers are reminded that a person’s possession of
an identification card is not a guarantee of their
enrollment, benefits or eligibility in a MA PPO Blue
Plan. A member’s identification, enrollment, benefits
and eligibility should always be verified in advance
of providing services except when verification is
delayed because of urgent or emergency situations.
Verification is easy!
Verifying benefits and eligibility for MA PPO out-ofstate Blue Plan members is easy! Just call BlueCard®
Eligibility at 1-800-676-BLUE (2583) and provide the
member’s alpha prefix information that is located on
their Blue Plan issued membership ID card. Blue
Medicare PPOSM providers who also participate with
BCBSNC have the added convenience to submit
electronic eligibility requests for out-of-state Blue
Plan members using Blue e.SM
4.9.2 Claims administration for out-of-area
MA PPO Blue Plan members
Network sharing for MA PPO out-of-state Blue Plan
members makes claims filing simple. After providing
services to eligible members, submit claims to BCBSNC.
Submit electronic claims to BCBSNC under your
current BCBSNC billing practices or enroll for
electronic claims filing with BCBSNC at our Durhambased claims address. Contact BCBSNC to set up
electronic billing by first visiting the electronic
solutions page of the BCBSNC Web site located at:
bcbsnc.com/content/providers/edi/index.htm.
If still filing claims using paper Claim Forms, send
claims for MA PPO out-of-state Blue Plan members
to BCBSNC at:
Blue Cross and Blue Shield of North Carolina
PO Box 35
Durham, NC 27702
Important!
Claims for services provided to MA PPO out-of-state
Blue Plan members should be sent to BCBSNC.
Medicare should not be billed directly.
Claims payment for services provided to MA PPO
out-of-state Blue Plan members will be based on
your contracted Blue Medicare PPOSM rate. Once
you submit a MA PPO claim to BCBSNC, the claim
will be forwarded to the member’s Blue Plan for
benefits processing. BCBSNC will work with the
member’s out-of-state Blue Plan to determine eligible
benefits and then send the payment directly to you.
PAGE 4-9
Chapter 4
Service area, ID cards, and provider verification of membership
MA PPO out-of-state Blue Plan members who see
Blue Medicare PPOSM participating providers will pay
in-network cost sharing (in-network; copayments,
coinsurance and deductibles). Providers may collect
any applicable copayment amounts from the
member at the time of service. Additionally,
providers may collect from members any deductible
and/or coinsurance amounts as reflected on the
payment remittance for a processed claim (members
may not be balance billed for any additional
amounts). If you have questions about a processed
MA PPO out-of-area Blue Plan member’s claim call
BCBSNC BlueCard® customer service for assistance
at 1-800-487-5522.
If you have any questions regarding the MA PPO
network sharing program for out-of-area Blue Plan
members, please contact Network Management.
SM
4.9.3 Medicare Advantage PPO network
sharing provider claim appeals
Network Provider Claim Appeals:
If you participate in the Blue Medicare PPOSM plan
offered by BCBSNC, you will be able to see Blue
Plan Medicare Advantage PPOSM members from outof-state Blue Plans. Claims for services provided to
out-of-state Blue Plan members will be reimbursed
in accordance with your Medicare Provider
Agreement with BCBSNC. If a participating provider
disagrees with claim processing for services
provided to an out-of state Blue Plan member, the
provider may submit a Network Provider Claim
Appeal for one of the following reasons:
• Payer allowance/pricing
• Incorrect payment/coding rules applied
• Benefit determinations made by the Home Plan
The Network Provider Claim Appeal must be
submitted in writing within ninety (90) days of claim
adjudication and may be mailed to:
Blue Medicare PPOSM
Attention: IPP Provider Appeals
PO Box 17509
Winston-Salem, NC 27116-7509
Eligible Network Provider Appeals concerning
out-of-state Blue Plan members will be completed
by the Plan within thirty (30) days of the Plan’s
receipt of all information.
Non-Network Provider Claim Appeals:
Providers who do not participate in the Blue
Medicare PPOSM plan offered by BCBSNC are not
eligible to see Blue MA PPO out-of-state members
as “in-network”. Such “out-of-network” providers will
receive the Medicare-allowed amount for covered
services, except for urgent or emergency care.
Urgent or emergency care will be reimbursed at the
member’s in-network benefit level. All other services
will be reimbursed at the member’s out-of-network
benefit level (when out-of-network benefits are
available) for nonparticipating providers.
If a provider disagrees with claim processing for
services provided to an out-of state Blue Plan
member, the provider may submit a Non-Network
Provider Claim Appeal for one (1) of the following
reasons:
• Medical policy/medical necessity (e.g., cosmetic
and investigational)
• Adverse organization determinations made by
the Home Plan
The Non-Network Provider Claim Appeal may be
submitted to the out-of-state member’s Blue Plan or
to the following address:
Blue Medicare PPOSM
Attention: IPP Provider Appeals
PO Box 17509
Winston-Salem, NC 27116-7509
PAGE 4-10
Chapter 5
Participating physician
responsibilities
Chapter 5
Participating physician responsibilities
5.1
Participating physician
responsibilities
BCBSNC Primary Care Physicians (PCPs) are
responsible for providing or arranging for all
appropriate medical services for BCBSNC members,
including preventive care, and the coordination of
overall care management for the patient. Members
enrolled in both the Blue Medicare HMOSM and Blue
Medicare PPOSM plans may be referred for care
outside of their primary care physician’s office
without a “referral” being written by the primary
care physician. However, members enrolled in the
Blue Medicare HMOSM plan do require advanced
authorization from BCBSNC if being referred to an
out-of-network (non-BCBSNC HMO) provider or
facility. The following specialists may serve as PCP’s
in certain situations:
• Family practice/general practice doctors
provide care for infants, children, adolescents
and adults in the areas of community
medicine, internal medicine, obstetrics and
gynecology, pediatrics, psychiatry and surgery.
• Internists (internal medicine) provide service
for treatment of diseases in adults. Normally,
they do not deliver babies, treat children or
perform surgery.
• Geriatric doctors provide care for older adults.
BCBSNC specialists are expected to render high
quality care appropriate to the needs of BCBSNC
members requiring specialized treatment.
5.2
Mental health and substance abuse
Members do not need a referral to access mental
health and substance abuse services. Members
should call our designated mental health substance
abuse administrator Magellan Health Services at
1-800-266-6167 to speak with a case manager.
5.3
Advance directives
(Please also refer to Chapter 3, Administrative
Policies and Procedures)
Medicare and Medicaid certified hospitals and other
health care providers (such as prepaid health plans
[HMOs]) must provide all adult members with
written information about their rights under state
law to make health care decisions, including the
right to exclude advance directives. The physician
providing care for adult BCBSNC members will
inquire about each adult member’s intention to
complete these directive documents and note in the
member’s medical record whether he/she has
executed an advance directive. Such notations will
be reviewed at the time of the recredentialing
medical record review.
5.4
Physician case management
services
Physician case management services including, but
not limited to, team conferences, telephone calls for
medical management and/or consultation,
prescriptions and prescription refills for BCBSNC
patients. Compensation for such services is subject
to BCBSNC fee schedules and policies, however,
BCBSNC fee schedule at this time allows no
compensation for services billed separately by CPT
or HCPCS case management codes. BCBSNC
considers such services part of overall case
management and compensation is included in
other payments to our providers.
BCBSNC patients must not be billed directly for
case management services.
PAGE 5-1
Chapter 5
Participating physician responsibilities
5.5
Physician availability
BCBSNC Primary Care Physicians (PCPs)*
BCBSNC PCPs are available twenty-four (24) hours a day, seven (7) days a week. If a physician is not available,
another BCBSNC contracted doctor will be available to provide access to care.
BCBSNC OB/GYNs*
BCBSNC gives women the advantage of having a PCP plus an OB/GYN. Women may see any BCBSNC
contracted OB/GYN without a referral from the PCP.
BCBSNC Vision Care Specialists*
No referral is required to access participating optometry or ophthalmology providers for vision care.
BCBSNC Physician Specialists*
Specialists servicing BCBSNC members are available twenty-four (24) hours a day, seven (7) days a week.
* Please see your certificate of coverage for more details, or call BCBSNC Customer Service at 1-888-310-4110,
Monday-Friday, 8:00 a.m. until 8:00 p.m. TTY/TDD 1-888-451-9957.
PAGE 5-2
Chapter 6
Quality Improvement
Program
Chapter 6
Quality Improvement Program
6.1
Quality Improvement overview
Blue Cross and Blue Shield of North Carolina (BCBSNC)1 believes Quality Improvement (QI) is an imperative
component of its managed care product offerings, which include Medicare Part C and D plans, Blue Medicare
HMO,SM Blue Medicare PPOSM and Blue Medicare Rx.
The Quality Improvement Program (QIP) supports BCBSNC’s ongoing commitment to quality, as stated in the
Mission Statement:
“Blue Cross and Blue Shield of North Carolina delivers value through quality products,
information and services to help our customers improve their health and well-being.”
BCBSNC promotes an environment dedicated to being caring, creative, collaborative, and committed.
Remaining true to the culture will help us achieve our vision to “be a leader in improving the health care
system in North Carolina.”
• Caring – We distinguish ourselves through superior customer focus and focusing on the larger good of
the organization through Enterprise thinking.
• Collaborative – We trust our colleagues. We do our best and most important work through teamwork.
We know openness to new ideas will help us shape the future of North Carolina’s health system.
• Committed – We show dedication to do our best work. We take personal accountability by having the
courage to identify problems, and the vision to create solutions.
• Creative – We know that embracing change is critical to our success. We focus on innovation and
problem solving. We share our ideas and seek opportunities for simplification and continuous improvement
every day.
Consistent with current professional knowledge, BCBSNC defines quality of care for individual populations as
the degree to which health services increase the likelihood of desired health outcomes. Quality of service is
defined as the ease and consistency with which customers obtain high quality care, as measured by customer
perception and objective benchmarks.2 This includes appropriate access to care.
In determining the scope and content of its Quality Improvement Program (QIP), BCBSNC recognizes several
concepts related to the delivery of health care, including:
• Quality of care and service is a crucial and integral component of health care delivery.
• Existing and potential customers’/groups’ unique needs and expectations must be satisfied and exceeded.
• Provider relationships with patients and the Plan must be continually improved.
• Legislative and regulatory requirements must be met and BCBSNC must provide leadership for efforts to
reform the health care system.
The Quality Improvement Program (QIP) is ongoing and designed to be proactive. It objectively and
systematically monitors the quality and appropriateness of the care, service, and access provided to members
through BCBSNC’s provider networks. The QIP then identifies, implements, monitors and evaluates
appropriate interventions to improve the quality of care and service. In other words, the QIP is intended to
link the concern for quality and the demonstrated improvement.
The QIP advocates the principles of Continuous Quality Improvement (CQI).
1 For the purposes of this summary, Blue Cross and Blue Shield of North Carolina (BCBSNC) refers to Blue Medicare HMO,SM Blue
Medicare PPOSM and Blue Medicare Rx lines of business.
2 Adapted from the Institute of Medicine.
PAGE 6-1
Chapter 6
Quality Improvement Program
CQI concepts and techniques including the Shewhart Cycle or Plan, Do, Study, Act (PDSA) model; population
statistics; and other relevant data sources help focus QI efforts and point to the need for specific projects
(Exhibit I). The QIP undergoes constant revision in order to more effectively monitor, evaluate, and
improve care.
The program goals are:
• To support corporate objectives and strategies, including cost-effectiveness and efficiency of care, while
continuously improving care outcomes and service delivered to BCBSNC members.
• To increase the accountability for results of care and service.
• To maintain member confidentiality, dignity, and safety as they seek and receive care.
• To foster a supportive environment to help practitioners and providers improve the safety of their practice.
• Utilizing evaluative feedback from customers and providers to assess and continually enhance care
delivery and outcomes.
• To improve clinical effectiveness.
• To incorporate QIP results into the selection and recredentialing of network providers and enhance the
network providers’ ability to deliver appropriate care and meet or exceed the expectations of the patient/
member.
• To enhance the overall marketability and positioning of BCBSNC as the best health care company in
North Carolina.
• To promote healthy lifestyles and reduce unhealthy behaviors in our members and throughout the
communities served.
• To collaborate with Magellan Behavioral Health and Value Options to promote continuity and coordination
between medical and behavioral health care.
• To minimize the administrative costs and burdens incurred by managed care methods.
• To maintain and enhance Quality Improvement processes and outcomes that satisfies the requirements of
the Centers for Medicare & Medicaid Services (CMS). Serve a culturally and linguistically diverse
membership by:
‡ Conducting patient focused interventions with culturally competent outreach materials
‡ Providing information, training, and tools to staff and practitioners to support culturally competent
communication.
• Demonstrate commitment to improving safe clinical practice by:
‡ Improve continuity and coordination of care between practitioners to avoid miscommunication that can
lead to poor outcomes
‡ Use site-visit results from practitioner and provider credentialing to improve safe practices
‡ Analyze and take action on complaint and satisfaction data that relate to clinical safety
‡ Implement pharmaceutical management practices that require safeguards to enhance patient safety
PAGE 6-2
Chapter 6
Quality Improvement Program
6.2
Network quality
At least every three (3) years, in conjunction with the re-credentialing process, our quality management
consultants visit primary care and OB/GYN physician practices to assess compliance to established access to
care, facility and medical record standards. This occurs at least every three (3) years.
Quality management consultants also play an educational role for physicians, assisting them in keeping up-todate with our latest documentation and facility requirements and keeping communication lines open between
BCBSNC and the network physicians.
The initiative described above has been recommended by community physicians who are members of our
Provider Advisory Group (PAG).
The following components of our network quality program are discussed below:
• Access to care standards
• Facility standards
• Medical record standards
6.2.1 Access to care standards – primary care physician
BCBSNC and the physician advisory group have established the following access to care standards for primary
care physicians.
EMERGENT CONCERNS (LIFE THREATENING) SHOULD BE REFERRED DIRECTLY TO 911 OR THE CLOSEST
EMERGENCY DEPARTMENT. IT IS NOT NECESSARY TO SEE THE PATIENT IN THE OFFICE FIRST.
1. Waiting time for appointment (number of days)
A. Urgent – not life threatening, but a problem needing care within 24 hours
Pediatrics
see within 24 hours
Adults
see within 24 hours
B. Symptomatic non-urgent – e.g., cold, no fever
Pediatrics
within 3 calendar days
Adults
within 3 calendar days
C. Follow-up of urgent care
Pediatrics
within 7 days
Adults
within 7 days
D. Chronic care follow-up – e.g., blood pressure checks, diabetes checks
Pediatrics
within 14 days
Adults
within 14 days
Continued on the following page.
PAGE 6-3
Chapter 6
Quality Improvement Program
E. Complete physical/health maintenance
Pediatrics
within 30 calendar days
Adults
within 60 calendar days
2. Time in waiting room (minutes)
A. Scheduled
30 minutes
After 30 minutes, patient must be given an update on waiting time with an option of waiting or rescheduling
appointment; maximum waiting time = 60 minutes
B. Work-ins / Walk-ins
(Called that day prior to coming)
Pediatrics and Adults – after 45 minutes, patient must be given an update on waiting time with an option
of waiting or rescheduling; maximum waiting time = 90 minutes.
BCBSNC discourages walk-ins, but reasonable efforts should be made to accommodate patients. Life
threatening emergencies must be managed immediately.
3. After hours calls and coverage
A. Response time returning call after-hours and during lunch
*Urgent
20 minutes
Other
1 hour
*Note: Most answering services cannot differentiate between urgent and non-urgent. Times indicated
make assumption that the member notifies the answering service that the call is urgent, and that the
physician receives enough information to make a determination.
B. Coverage
Practice has a recorded telephone message instructing the patient to go to the ER for any life threatening event or
refer them to the physician on-call or to an answering service.
4. Language
Interpreter services are available either in the practice, with a contracted company (AT&T) or through
hospital services.
Continued on the following page.
PAGE 6-4
Chapter 6
Quality Improvement Program
5. Office hours
Indicates the posted hours during which appropriate personnel is available
Daytime hours/week
7 hours per day x 5 days = 35 hours
Night hours/weekend
24 hour/day coverage
6.2.2 Access to care standards – specialist (including non-MD specialist)
The following access to care standards for specialists have been established by the BCBSNC physician advisory
group. Non-MD specialists are Chiropractors (DC), Podiatry (DPM), Physical Therapy (PT), Speech Therapy (ST),
and Occupational Therapy (OT).
1. Waiting time for appointment (number of days)
A. Urgent – not life threatening, but a problem needing care within 24 hours:
Pediatrics
see within 24 hours
Adults
see within 24 hours
B. Regular
Pediatrics
(e.g., tube referral) – within 2 weeks
Adults
SUB-ACUTE PROBLEM (of short duration) – within 2 weeks
CHRONIC PROBLEM (needs long time for consultation) – within 4 weeks
2. Time in waiting room (minutes)
A. Scheduled
After 30 minutes, patient must be given an update on waiting time with an option of waiting or rescheduling
appointment; maximum waiting time = 60 minutes
B. Work-ins
(called that day prior to coming)
Pediatrics and Adults – after 45 minutes, patient must be given an update on waiting time with an option of
waiting or rescheduling; maximum waiting time = 90 minutes
Continued on the following page.
PAGE 6-5
Chapter 6
Quality Improvement Program
3. After hours calls and coverage
A. Response time returning call after-hours
*Urgent
20 minutes
Other
1 hour
B. Coverage
Practice has a recorded telephone message instructing the patient to call 911 or go to the ER for any life threatening
event or refer them to the physician on-call or to an answering service.
Daytime hours/week
40 hours/week
Night hours/weekend
24 hour/day coverage
4. Language
Interpreter services are available either in the practice, with a contracted interpreter phone line or through
hospital interpreter services.
5. Office hours
Indicates hours during which appropriate personnel is available to care for members
Daytime hours/week
15 hours/week minimum covering at least 4 days
PAGE 6-6
Chapter 6
Quality Improvement Program
6.2.3 Facility standards
The following standards for the facilities of practices participating in our managed care programs have been
adopted by Blue Cross and Blue Shield of North Carolina and endorsed by the physician advisory group for
use in assessing the environment in which health care is provided to our members.
1. The general appearance of the facility provides an inviting, organized and professional demeanor
including, but not limited to, the following:
a. The office name is clearly visible from the street.
b. The grounds are well maintained; patient parking is adequate with easy traffic flow.
c. The waiting area(s) are clean with adequate seating for patients and family members.
d. Exam and treatment rooms are clean, have adequate space and provide privacy for patients.
Conversations in the office/treatment area should be inaudible in the waiting area.
2. There are clearly marked handicapped parking space(s) and handicapped access to the facility or a
documented process for assisting handicapped patients into the building.
3. A smoke-free environment is promoted and provided for patients and family members.
4a. A fire extinguisher is clearly visible and is readily available.
4b. Fire extinguishers are checked and tagged yearly.
5. Designated toilet and bathing facilities are easily accessible and equipped for the handicapped
(i.e., grab bars).
6a. There is an evacuation plan posted in a prominent place or exits are clearly marked, visible, and
unobstructed.
6b. There is an emergency lighting source.
7. Halls, storage areas, and stairwells are neat and uncluttered.
8. There are written policies and procedures to effectively preserve patient confidentiality. The policy
specifically addresses: 1) how informed consent is obtained for the release of any personal health
information currently existing or developed during the course of treatment to any outside entity, i.e.,
specialists, hospitals, 3rd party payers, state or federal agencies; and 2) how informed consent of
release of medical records, including current and previous medical records from other providers which
are part of the medical record, is obtained.
8a. All employees including the contract transcriptionists, If applicable, sign a written confidentiality statement.
9. Restricted, biohazard, or abusable materials (i.e., drugs, needles, syringes, prescription pads, and
patient medical records) are secured and accessible only to authorized office/medical personnel.
Archived medical records and records of deceased patients should be stored and protected for
confidentiality.
9a. Controlled substances are maintained in a locked container/cabinet. A record is maintained of use.
9b. There is a procedure for monitoring expiration dates of all medications in the office (i.e., medications log)
*10. Dedicated emergency kit is available which must include sufficient equipment/supplies to support life
until patient can be moved to an acute care facility (at minimum: ambu bag (adult and pediatric, if
applicable) and oxygen).
*10a. At least one staff member is certified in CPR or basic life support.
PAGE 6-7
Chapter 6
Quality Improvement Program
*10b. Emergency procedures are in place and are reviewed with staff members annually. Review must be
documented.
*10c. Emergency supplies include, but are not limited to, emergency medications (aspirin [adults only], oral
glucose, epinephrine, and Benadryl).
*10d. Emergency supplies are checked routinely for expiration dates. A log is maintained documenting the
routine checks.
11. There is a written procedure which is in compliance with state regulations for oversight of mid-level
practitioners.
12. There is a procedure for ensuring that all licensed personnel have a current, valid license.
13. A written infection control policy/program is maintained by the practice.
14. There is an annual review and staff in-service on infection control.
15. Sterilization procedures and equipment are in place and being followed.
16. The practice has an Automated External Defibrillator (AED) as part of the emergency equipment and
maintains a log to check functionality (not scored).
Note: Standards preceded by an asterisk (*) are critical elements. Failure to comply with any of these (numbers
eleven [11] and twelve [12] inclusively) could result in a shortened credentialing cycle or possible removal from
the network. Failure of a critical indicator is taken to the credentialing committee the month of the review.
6.2.4 Medical record standards for primary care providers and OB/GYN providers
Standard
Supporting documentation
1. All pages contain patient identification
1. Each page in the medical record must contain
the patient’s name or I.D. number.
2. Each record contains biological/personal data
2. Biographical/personal data is noted in the
medical record. This includes the patient’s
address, employer, home and work telephone
numbers, date of birth and marital status. This
data should be updated periodically.
3. The provider is identified on each entry
3. Each entry in the medical record must contain
author identification (signature or initials).
4. All entries are dated
4. Each entry in the medical record must include the
date (month, day, and year).
5. The record is legible
5. The medical record must be legible to someone
other than the writer.
6. There is a completed problem list
6. The flow sheet includes age appropriate
preventive health services. A BLANK PROBLEM
LIST OR FLOW SHEET DOES NOT MEET THIS
STANDARD.
Continued on the following page.
PAGE 6-8
Chapter 6
Quality Improvement Program
Standard
Supporting documentation
7. Allergies and adverse reactions to medications
are prominently displayed
7. Medication allergies and adverse reactions are
PROMINENTLY noted in a CONSISTENT place
in each medical record. If significant, allergies to
food and/or substances may also be included.
Absence of allergies must also be noted. Use
NKA (no known allergy) or NKDA (no known drug
allergy) to signify this. It is best to date all allergy
notations and update the information at least
yearly.
8. The record contains an appropriate past
medical history
8. Past medical history (for patients seen 3 or more
times) is easily identified and includes serious
accidents, operations, illnesses. For children and
adolescents (age 18 and younger) past medical
history relates to prenatal care, birth, operations
and childhood illness. The medical history should
be updated periodically.
9. Documentation of smoking habits and alcohol
use and substance abuse is noted in the record
9. The medical record should reflect the use of or
abstention from smoking (cigarettes, cigars,
pipes, and smokeless tobacco), alcohol (beer,
wine, liquor), and substance abuse (prescription,
over-the-counter, and street drugs) for all patients
age 12 and above who have been seen 3 or
more times. It is best to include the amount,
frequency, and type in use notations.
10. The record includes a history and physical
exam for presenting complaints
10. The history and physical documents appropriate
subjective and objective information for
presenting complaints.
11. Lab and other diagnostic studies are ordered
as appropriate
11. Lab and other diagnostic studies are ordered as
appropriate to presenting complaints, current
diagnosis, preventive care, and follow-up care
for chronic conditions. It is best to note if the
patient refuses to have recommended lab or
other studies performed.
12. The working diagnoses are consistent with the
diagnostic findings
12. The working diagnosis is consistent with the
findings from the physical examination and the
diagnostic studies.
13. Plans of action/treatments are consistent with
the diagnosis(es)
13. Treatment plans are consistent with the
diagnosis.
Continued on the following page.
PAGE 6-9
Chapter 6
Quality Improvement Program
Standard
Supporting documentation
14. Each encounter includes a date for a return visit
or other follow-up plan
14. Each encounter has a notation in the medical
record concerning follow-up care, calls, or
return visits. The specific time should be noted
in days, weeks, months, or PRN (as needed).
15. Problems from previous visits are addressed
15. Unresolved problems from previous office visits
are addressed in subsequent visits.
16. Appropriate use of consultant services is
documented
16. Documentation in the record supports the
appropriateness and necessity of consultant
services for the presenting symptoms and/or
diagnosis.
17. Continuity and coordination of care between
primary and specialty physicians or agency
documented
17. If a consult has been requested and approved,
there should be a consultation note in the
medical record from the provider (including
consulting specialist, SNF, home infusion
therapy provider, etc.)
17. Continuity and coordination of care between
primary and specialty physicians or agency
documented
17. If a consult has been requested and approved,
there should be a consultation note in the
medical record from the provider (including
consulting specialist, SNF, home infusion
therapy provider, etc.).
18. Consultant summaries, lab and imaging study
results reflect review by the primary care
physician
18. Consultation, lab, and x-ray reports filed in the
medical record are initialed by the primary care
physician or some other electronic method is
used to signify review. Consultation, abnormal
lab, and imaging study results have an explicit
notation in the record of follow-up plans.
19. Care is demonstrated to be medically
appropriate
19. Medical record documentation verifies that the
patient was not placed at inappropriate risk as
a result of a diagnostic or therapeutic process.
20. A complete immunization record is included in
the chart
20. Pediatric medical records contain a completed
immunization record or a notation that
“immunizations are up-to-date.”
Continued on the following page.
PAGE 6-10
Chapter 6
Quality Improvement Program
Standard
Supporting documentation
21. Appropriate use of preventive services is
documented
21. There is evidence in the medical record that
age appropriate preventive screening and
services are offered in accordance with the
organization’s practice guidelines. (Refer to the
Medical Policy section of your provider manual.)
It is best to note if patient refuses recommended
screenings and/or services (3 or more visits
every 3 years).
22. Charts are maintained in an organized format
22. There is a record keeping system in place that
ensures all charts are maintained in an
organized and uniform manner. All information
related to the patient is filed in the appropriate
place in the chart.
23. There is an adequate tracking method in place
to insure retrievability of every medical record
23. Each medical record required for patient visit or
requested for review should be readily available.
24. Review of chronic medications, if appropriate,
for the presenting symptoms
24. There is documentation in the record, either
through the use of a medication sheet or in the
progress notes, that medications have been
discussed as appropriate.
25. Each record of a Blue Medicare HMO or Blue
Medicare PPO member includes information
regarding advanced directives.
25. The medical record of a Blue Medicare HMO
or Blue Medicare PPO member has a
documented notation of whether the member
has executed an advanced directive.
26. The primary care medical record of Blue
Medicare HMO or Blue Medicare PPO
members include documentation of the Health
Risk Assessment (HRA).
26. The report of the initial Health Risk Assessment
(HRA) of Blue Medicare HMO or Blue Medicare
PPO members determined to be potentially
at a high-risk status should be evident in the
medical records. There is documentation of
review by the PCP, and the treatment plan
incorporates information from the risk
assessment.
SM
SM
SM
SM
Documentation of medical record format used
in practice
SM
SM
SM
SM
• Paper
• EMR – Electronic Medical Record system is a
medical record in an electronic format.
• EHR – Electronic Health Record is a system
that is electronic and has searchable data
fields that allow reports to be run.
• Name of EHR system and the version being
used.
PAGE 6-11
Chapter 6
Quality Improvement Program
6.3
Clinical practice and preventive care guidelines overview
Clinical practice and preventive care guidelines help clarify care expectations and, when possible, are
developed based on evidence of successful practice protocols and treatment patterns. Clinical practice
guidelines are intended to be used as a basis to evaluate the care that could be reasonably expected under
optimal circumstances. Preventive care guidelines provide screening, testing, and service recommendations
based upon national standards.
Nationally accepted guidelines
BCBSNC endorses the following nationally recognized clinical practice and preventive care guidelines:
Practice guidelines
COPD
Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD), based on the collaborative
recommendations of the World Health Organization and the National Heart, Lung and Blood Institute:
Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD (Guidelines)
Web site: www.goldcopd.com
Diabetes
Source: American Diabetes Association: Clinical Practice Recommendations
Web site: www.diabetes.org
Heart failure
Source: ACCF/AHA Guideline for the Management of Heart Failure
Web site: www.heart.org
Hypertension
Source: National Institutes of Health National Heart Lung Blood Institute – Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
Web site: www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
Coronary Artery Disease (CAD)
Source: American Heart Association
Web site: www.heart.org
Tobacco counseling
Source: U.S. Preventive Services Task Force
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Continued on the following page.
PAGE 6-12
Chapter 6
Quality Improvement Program
Practice guidelines (continued)
Prenatal care
Source: American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, 7th edition
Web site: sales.acog.org/Guidelines-for-Perinatal-Care-Seventh-Edition-P262C54.aspx
Depression
Source: American Psychiatric Association
Web site: psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485
Preventive health guidelines
Preventive health guidelines are standards of care developed to encourage the appropriate provision of
preventive services to patients, according to their age, gender, and risk-status. These services include
screenings, immunizations, and physical examinations.
Preventive health guidelines
Initial medical evaluation of adults
Sources: U.S. Preventive Services Task Force; American Academy of Family Physicians
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Web site: www.aafp.org/online/en/home/clinical/exam.html
Periodic health assessment for newborn/infants to 24 months
Source: U.S. Preventive Services Task Force
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Periodic health assessment for children and adolescents, 2-19 years old
Sources: U.S. Preventive Services Task Force; American Academy of Family Physicians
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Web site: www.aafp.org/online/en/home/clinical/exam.html
Periodic health assessment for adults, 20-64 years old
Sources: United States Preventive Services Task Force (USPSTF), Guide to Clinical Preventive Services;
American Academy of Family Physicians, Summary of Recommendations for Clinical Preventive Services
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Web site: www.aafp.org/online/en/home/clinical/exam.html
Continued on the following page.
PAGE 6-13
Chapter 6
Quality Improvement Program
Preventive health guidelines (continued)
Periodic health assessment for adults, 65 years and older
Sources: United States Preventive Services Task Force (USPSTF), Guide to Clinical Preventive Services;
American Academy of Family Physicians, Summary of Recommendations for Clinical Preventive Services
Web site: www.uspreventiveservicestaskforce.org/recommendations.htm
Web site: www.aafp.org/online/en/home/clinical/exam.html
Routine immunizations
Source: Centers for Disease Control and Prevention
Web site: www.cdc.gov/vaccines
Please note that guidelines are subject to change. Providers are encouraged to visit the Web sites for the
nationally recognized clinical practice and preventive care guidelines regularly, to receive the most current
and up-to-date information available.
PAGE 6-14
Chapter 7
Emergency care coverage
Chapter 7
Emergency care coverage
7.1
Emergency care coverage
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient
severity; including but not limited to severe pain, or by acute symptoms developing from a chronic medical
condition, that would lead a prudent layperson, possessing an average knowledge of health and medicine, to
reasonably expect the absence of immediate medical attention to result in placing the health of an individual
or unborn child in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily
organ or part.
Emergency services are covered inpatient or outpatient services which are (1) furnished by a provider qualified
to furnish emergency services and (2) needed to stabilize or evaluate a emergency medical condition.
Coverage is provided worldwide and prior authorization is not required.
If a member experiences an emergency medical condition, he/she is advised to seek care from the nearest
medical facility, call 911 or to seek direction and/or treatment from a physician.
7.2
Urgently needed services
Urgently needed services are covered services, that are not emergency services, provided when an enrollee is
temporarily absent from the Plan’s service area (or, under unusual and extraordinary circumstances, provided
when the enrollee is in the service area but the Plan’s provider network is temporarily unavailable or
inaccessible) when such services are medically necessary and immediately required:
1) As a result of an unforeseen illness, injury or condition, and
2) It was not reasonable given the circumstances to obtain the services through Plan providers
If such a medical need arises, we request that member or a representative contact the member’s PCP if
possible, then seek care from a local doctor or other provider as directed by the PCP. If the member is unable
to do the above, he/she may seek care from a hospital emergency room or urgent care center. Prior
authorization is not required for urgently needed services.
PAGE 7-1
Chapter 8
Utilization management
programs
Chapter 8
Utilization management programs
8.1
Affirmative action statement
Blue Cross and Blue Shield of North Carolina
(BCBSNC), and its associated delegates require
practitioners, providers and staff who make
utilization management-related decisions to make
those decisions solely based on appropriateness of
care and service and existence of coverage.
BCBSNC does not compensate or provide any other
incentives to any practitioner or other individual
conducting utilization management review to
encourage denials. BCBSNC makes it clear to all
staff that make utilization management decisions
that no compensation or incentives are in any way
meant to encourage decisions that would result in
barriers to care, service or under-utilization of services.
8.2
Pre-authorization review
BCBSNC reviews health care service requests prior
to an admission or initiation of a course of treatment
for those services that require pre-authorization (as
specified elsewhere in this manual). Pre-authorization
decisions will be made as expeditiously as the
member’s condition requires, but no later than
fourteen (14) calendar days after the Plan receives
the request (or within seventy-two [72] hours for
expedited requests). An extension of up to fourteen
(14) calendar days may be given if the member so
requests or if the Plan justifies a need for additional
information and exhibits how the delay is in the best
interest of the member. Authorized services and
subsequent review dates are communicated verbally
to the requesting provider, and in writing where
required by Federal or CMS regulations. Notification
of organization determinations will comply with
requirements outlined by CMS.
8.3
Inpatient review
BCBSNC licensed nurses perform both telephonic
and on-site reviews for emergency admissions and
ongoing hospital stays to determine medical necessity,
facilitate early discharge planning and to assure
timely and efficient health care services are provided.
Coverage determinations are made as expeditiously
as the member’s health condition requires.
8.4
Medical case management
BCBSNC reviews specific needs of members whose
conditions are complex, serious, complicated,
chronic or indicative of long term or high cost
medical care, and assists physicians and health care
team members to coordinate delivery of high quality
services for members in the most effective manner
possible. See additional information at
bcbsnc.com/content/medicare/member/health/
case-management.htm.
8.5
Ambulatory review
Some services performed or provided in an
outpatient setting, such as physician offices, hospital
outpatient facilities or, freestanding surgicenters,
require prior authorization. If prior authorization is
not required, retrospective review may be conducted
to ensure that care provided is necessary and
medically indicated.
8.6
Hospital observation
Observation services are those services furnished by
a hospital on the hospital’s premises, including use
of a bed and periodic monitoring by a hospital’s
nursing or other staff, which are reasonable and
necessary to evaluate a patient’s outpatient
condition or determine the need for a possible
admission to the hospital as an inpatient.
An admission to observation by the attending
physician does not require prior plan approval.
In order to be successful in assuring medically
appropriate, quality care, we rely on your cooperation.
Timely, appropriate reviews require prompt notification
of inpatient admissions, the submission of complete
medical information or access to patient charts and
specification of discharge needs. If after the initial
observation period the member’s clinical status
deteriorates or remains unstable and/or additional
clinical information is provided which meets MCG
(Milliman Care Guidelines) for admission, the nurse
may authorize an inpatient stay retroactive to the
date of the member’s admission to the facility as an
observation patient.
PAGE 8-1
Chapter 8
Utilization management programs
If the member has been discharged, at the time the
hospital notifies the Plan of the inpatient admission,
the review of the observation to inpatient level of
care will be completed when the claim is processed.
8.7
Diagnostic imaging services
BCBSNC initiated its diagnostic imaging management
program for commercial members in 2007 to ensure
that high-tech diagnostic imaging services are
performed at the appropriate time and in the
appropriate sequence. The Centers for Medicare &
Medicaid Services encourage the avoidance of overutilization and promotes patient safety in connection
with diagnostic imaging. To promote these goals,
BCBSNC extended its diagnostic imaging
management program to include members covered
under the BCBSNC Medicare Advantage products;
Blue Medicare HMOSM and Blue Medicare PPOSM on
September 1, 2010. The program requires prior
authorization for the (non-emergency) high tech
diagnostic imaging services listed below when
performed in a physician’s office, the outpatient
department of a hospital, or a freestanding imaging
center:
• CT/CTA scans
• MRI/MRA scans
• Nuclear cardiology studies
• PET scans
• Echocardiography
Additional information about the diagnostic imaging
program for Blue Medicare HMOSM and Blue Medicare
PPOSM members is available in this manual located in
Chapter 9, Section 9.5 and on the Web site at
providers.bcbsnc.com/providers/imaging.faces.
8.8
Medical Director’s responsibility
It is the policy of BCBSNC to have a Medical Director
review any case involving questionable medical
necessity.
This policy is designed to ensure that Medical
Directors are involved in the Utilization Management
(UM) decision process. Final determinations ensure
that medically necessary, safe and cost-effective care
is rendered in the most appropriate setting or level
of care.
The Medical Director may be able to make a
determination based on the information provided;
however, in some cases, the Medical Director may
request additional clinical information or elect to
contact the attending physician to obtain additional
information, to discuss an alternative treatment plan,
or to review the decision with the provider.
8.9
New technology and new
application of established
technology review
BCBSNC reviews new technologies and new
applications of established technologies in a timely
manner and may approve or deny coverage for use
of a new technology or new application of an
established technology. “Technologies” may include
treatments, supplies, devices, medications and
procedures. The review of new technologies and
new applications of existing technologies is based
on a standardized process which considers formal
research, existing protocols, potential risks and
benefits, costs, effectiveness and governmental
approvals. BCBSNC complies with decisions of local
carriers based on local coverage determinations
and CMS national coverage determinations and
guidelines.
8.10
Retrospective review
Retrospective medical necessity review may be
conducted when notification is received for services
already provided. The review of the retrospective
service will be completed when the claim is
processed.
PAGE 8-2
Chapter 8
Utilization management programs
Non-certification of service requests
BCBSNC may deny coverage for an admission,
continued stay or other health care service.
Non-certification determinations based on BCBSNC
requirements for medical necessity, appropriateness,
health care setting or level of care or effectiveness,
are made by the BCBSNC Medical Director.
Written notification of general non-certifications are
mailed by BCBSNC to the member and provider(s)
within the CMS timelines for the case under review.
Non-certifications will include reasons for the
non-certification, including the clinical rationale,
alternative for treatment that BCBSNC deems
appropriate, and instructions for initiating a voluntary
appeal or reconsideration of the non-certification.
Non-certifications related to skilled nursing facilities,
home health and comprehensive outpatient
rehabilitation facility services are distributed by the
provider within two (2) business days prior to the
end of the service authorization or termination
of services.
Coverage for services which are subject to the
exclusions, conditions and limitations outlined in the
member’s evidence of coverage and consistent with
Original Medicare coverage guidelines may be
denied by the BCBSNC review staff without review
by the BCBSNC Medical Director.
8.11
Standard data elements
Information required to make utilization management
decisions and to certify an admission, procedure or
treatment, length of stay and frequency and
duration of health care may include:
• Clinical information, including primary diagnosis,
secondary diagnosis, procedures or treatments,
if any.
• Pertinent clinical information to support
appropriateness and level of service requests,
such as history and physical, laboratory findings,
progress notes, second opinions and any
discharge planning.
• Resources, including facility type, name, address
and telephone, any surgical assistant information,
anesthesia if any, admission date, procedure
date and requested length of stay.
• Continued stay if any, including date, entity
contact, provider contact, additional days or
visits requested, reason for extension, diagnosis
and treatment plan.
Occasionally after making a reasonable effort, the
necessary clinical information may not be available
or obtainable to make a coverage determination.
Coverage decisions will be based on the clinical
information available at the time of review.
8.12
Disclosure of utilization
management criteria
Participating providers, covered members and bona
fide prospective participants may receive copies of
the following upon request:
• An explanation of the utilization review criteria
and treatment protocol under which treatments
are provided for conditions specified by covered
or prospective members. The explanation may
be in writing if so requested.
• Written reasons for denial of recommended
treatments and an explanation of the clinical
review criteria or treatment protocol upon which
the denial was based.
• The BCBSNC formulary and prior authorization
requirements for obtaining prescription drugs,
whether a particular drug or therapeutic class of
drugs is excluded from its formulary, and the
circumstances under which a non-formulary drug
may be covered.
• The BCBSNC procedures and medically based
criteria for determining whether a specified
procedure, test or treatment is experimental.
PAGE 8-3
Chapter 8
Utilization management programs
8.13
Care coordination services
Because of the unique health care needs of the
Medicare population, health care providers must
work as a team to provide and arrange for those
necessary health care services. To accomplish this,
BCBSNC and some of the contracting providers are
using a care coordination approach.
Care coordination is personal, individualized and
proactive assistance/intervention for providers and
members. Continuing interaction between a nurse
case manager and a patient under the supervision
of the primary care physician can accomplish the
following goals:
• Improve access to appropriate care through the
availability of a full continuum of health care
services including: preventive care, acute care,
primary care, specialty care, long term care and
home health services
• Match and manage patient health care needs to
ensure appropriate, effective and efficient
delivery of care
• Instruct and reassure the patients and families
• Increase the utilization and benefit of patient
education, particularly in the areas of
understanding disease processes and therapy,
promotion of wellness and health risk reduction
• Coordinate care between different providers
• Avoid duplication of diagnostic tests and
procedures
The case manager functions as an ombudsman for
the patient and the patient’s family and as a
facilitator and extender for the primary care
physician. In this role, the care coordinator:
• Conducts health status/risk assessments
• Investigates, reports and assists in resolving
complicating social and environmental problems
• Increases compliance with preventive and
therapeutic programs
• Reviews and follows pharmaceuticals and other
therapy to improve compliance and avoid
unwanted drug interactions and reactions
• Coordinates social services outside the hospital
setting
8.14
Service determination
Requests from providers for coverage of services will
be responded to as expeditiously as the member’s
health requires (BCBSNC normally has up to
fourteen [14] calendar days). In instances where the
member’s health or ability to regain maximum
function could be jeopardized by waiting up to
fourteen (14) calendar days, the provider requesting
coverage of services may request an expedited
review, in which case the request will be responded
to within seventy-two (72) hours. In either case, an
extension of up to fourteen (14) calendar days is
permitted, if the member requests the extension or
if the Plan justifies a need for additional information
and the extension of time benefits the member. For
example, the Plan might need additional medical
records from non-contracting medical providers that
could change a denial decision. When the Plan
takes an extension, the member will be notified of
the extension in writing. Also in either case, the
member will be notified in writing of any adverse
coverage determination.
In situations where a member requests that a
physician provide a service, and the provider does
not believe that the service is appropriate and
therefore chooses not to provide it, the member or
authorized representative may contact BCBSNC to
appeal the provider’s decision. To ensure that a
member is notified of appeals rights regarding
determinations, providers must notify the member
of his/her right to receive from BCBSNC, upon
request, a detailed written notice regarding the
denial and provide the member with information
regarding how to contact BCBSNC.
• Facilities transfer of information between
providers and sites of care
PAGE 8-4
Chapter 9
Prior authorization
requirements
Chapter 9
Prior authorization requirements
9.1
Prior authorization guidelines
Prior authorization is not required for DME that costs
less than $600 if all of the following criteria are met:
Prior authorization is a system whereby a provider or
in the case of the PPO, the member must receive
approval from BCBSNC before certain services will be
covered in accordance with the member’s evidence
of coverage.
2. A BCBSNC contracting provider prescribes the
DME.
Services requiring prior authorization by BCBSNC
depends on whether the member has chosen PPO
or HMO coverage.
4. The DME is provided by or obtained from a
provider/vendor who is contracting with BCBSNC.
Cosmetic procedures are excluded in the evidence
of coverage. Please contact the Care Management
& Operations department for assistance in
determining whether a procedure would be
considered cosmetic or medically necessary.
Refer to BCBSNC formulary for medications which
may require prior authorization. Refer to member’s
evidence of coverage for specific coverage of
benefits.
To obtain prior authorization, providers can call
1-336-774-5400 or 1-888-296-9790 to reach
BCBSNC Care Management & Operations.
Services on the BCBSNC prior authorization
guideline list require the PCP authorized specialist
or PPO member to contact BCBSNC Care
Management & Operations department to obtain an
authorization. This list is reviewed periodically and
may be changed with appropriate notification to
physicians. Prior authorization guidelines are available
for review on the Web site at bcbsnc.com/content/
providers/blue-medicare-providers/index.htm.
You can also contact Network
Management to request a current copy.
9.2
Requesting durable medical
equipment and home health
services
Contracting providers with Blue Cross and Blue
Shield of North Carolina (BCBSNC) agree to follow
BCBSNC’s prior authorization guidelines when
ordering or dispensing Durable Medical Equipment
(DME) for BCBSNC members. BCBSNC’s prior
authorization guidelines can be found on the
BCBSNC Web site at bcbsnc.com/content/
providers/blue-medicare-providers/index.htm.
1. The DME must be for purchase only.
3. BCBSNC considers the DME to be medically
necessary.
5. The DME claim is submitted to BCBSNC with a
valid HCPCS code and is assigned a BCBSNC
contracted rate.
Prior authorization from BCBSNC is required for all
DME in the following circumstances:
1. DME items which cost more than $600.
2. All rental items require prior authorization from
BCBSNC.
3. Support devices and supplies require prior
authorization if the cost exceeds $600.
4. Any eligible DME item that is provided as
incidental to a physician’s office visit.
5. DME provided by a home care provider during
a covered home care visit.
6. Equipment and/or supplies used to assure the
proper functioning of BCBSNC approved DME
(equipment or prosthetic).
7. DME provided by a home infusion provider
during a covered visit.
Providers may obtain prior authorization by calling
BCBSNC provider services at 1-888-296-9790.
Please be prepared to provide the relevant clinical
information to support the medical necessity of the
DME request along with the following required
information:
• Patient’s name
• Patient’s BCBSNC ID number
• Type of service or DME requested
• Patient’s diagnosis/medical justification in
relation to the requested service
• Start and stop date of services
• Ordering physician’s name
PAGE 9-1
Chapter 9
Prior authorization requirements
Participating home health/DME vendors are listed in
the online provider directory for information only
and should not be directly contacted for services.
Home health/DME services requiring arrangement
on weekends and after BCBSNC business hours may
be retrospectively authorized the next business day
if medical justification is met and participating
vendors are utilized.
9.3
Prosthetics
Contracting providers in BCBSNC Medicare
Advantage plans agree to follow BCBSNC’s prior
authorization guidelines when ordering or dispensing
prosthetics for BCBSNC members. BCBSNC’s prior
authorization guidelines can be found on the BCBSNC
Web site at bcbsnc.com/content/providers/bluemedicare-providers/index.htm.
Coverage will be provided for prostheses and
components when it is determined to be medically
necessary and when the medical criteria and
guidelines are met as outlined in BCBSNC’s
Medicare C/D Medical Coverage Policy. BCBSNC
medical coverage policies can be found on the
BCBSNC Web site at bcbsnc.com/content/
providers/blue-medicare-providers/index.htm.
Covered services requiring prior authorization
from BCBSNC:
• A lower limb prosthetic is covered when the
member:
‡ Will reach or maintain a defined functional
state within a reasonable period of time and;
‡ When the member is motivated to ambulate.
• An upper limb prosthetic is covered to replace
all or part of the function of permanently
inoperative or malfunctioning extremity
• Prosthetic substitutions and/or additions of
procedures and components are covered in
accordance with the functional level assessment
when an initial above or below knee prosthetic
or a preparatory above knee prosthetic is provided.
An explanation of “functional levels” is outlined
in BCBSNC’s medical coverage policy titled,
“Prostheses – Artificial Limbs and Components”
.
The medical coverage policy can be accessed at
bcbsnc.com/content/providers/blue-medicareproviders/medical-policies/index.htm.
• Stump stockings and harnesses (including
replacements) are also covered when these
appliances are essential to the effective use of
the artificial limb.
Noncovered services:
• Coverage will not be approved when the
member’s functional level is “0”. BCBSNC’s
Medical Coverage Policy defines a member’s
functional level as “0” when the member does
not have the ability or potential to ambulate or
transfer safely with or without assistance and a
prosthetic does not enhance their quality of life
or mobility.
• A user-adjustable heel height feature will be
denied as not reasonable and necessary.
• Routine periodic servicing, such as testing,
cleaning, and checking of the prosthetic.
• Prosthetic donning sleeve.
• Repair time used for the following:
‡ Evaluating the member
‡ Taking measurements
‡ Making modifications to a prefabricated item
to fit the member
‡ Follow-up visits
‡ Making adjustments at the time of delivery, or
within ninety (90) days after delivery;
Providers may obtain prior authorization by calling
BCBSNC provider services at 1-888-296-9790.
Please be prepared to provide the relevant clinical
information to support the medical necessity of the
prosthetic request.
PAGE 9-2
Chapter 9
Prior authorization requirements
9.4
Power-operated vehicle/motorized wheelchair requests
In response to the Centers for Medicare & Medicaid Services’ (CMS) revised policy for the coverage of power
wheelchairs, power-operated vehicles (scooters), and manual wheelchairs, and because power-mobility devices
require prior authorization from BCBSNC, we have developed the Medicare Advantage Power-Operated
Vehicle (POV)/Motorized Wheelchair Request form. The ordering physician’s office must contact BCBSNC to
obtain prior authorization from BCBSNC Care Management & Operations.
You may copy and use the Medicare Advantage Power-Operated Vehicle (POV)/Motorized Wheelchair
Request form (see Chapter 24, Forms). Additional copies of this form may be downloaded from the provider
resources section on our Web site at bcbsnc.com/content/providers/blue-medicare-providers/index.htm.
The complete CMS policy for Power-Mobility Devices (PMD) may be viewed on the CMS Web site at
cms.hhs.gov/coverage.
PAGE 9-3
Chapter 9
Prior authorization requirements
9.4.1 Sample Medicare Advantage – Power Operated Vehicle (POV)/motorized wheelchair request form
Medicare Advantage – Power Operated Vehicle (POV)/Motorized Wheelchair Request Form
Patient Name:
Patient ID# and Date of Birth:
Physician Name:
Physician Phone Number:
DME Item Requested (check only one box):
POV/Scooter
Patient’s Medical Diagnosis(es):
Motorized Wheelchair
Please answer the questions below. Submit this form and all medical records to support your answers and the medical necessity of the
requested equipment. The medical notes must be submitted with this request.
1. Does the patient have a mobility limitation that significantly impairs his/her ability to participate in one or more mobilityrelated activities of a daily living (MRADLs) in the home?
Yes
No
Yes
No
3. Can the patient’s mobility needs in the home be sufficiently resolved with the use of a cane or walker?
Yes
No
4. Can the patient’s mobility needs in the home be sufficiently resolved with the use of a manual wheelchair?
Yes
No
5. Does the patient’s typical environment support the use of wheelchairs including scooters/POVs?
Yes
No
6. Does the patient have sufficient upper extremity function to propel a manual wheelchair in the home to
participate in MRADLs during a typical day?
Yes
No
7. Does the patient have sufficient strength and postural stability to operate a POV/scooter?
Yes
No
8. If a power wheelchair is being requested, are the features requested needed to allow the patient to participate in
one (1) or more MRADLs?
Yes
No
If yes, please describe the specific mobility limitation and quantify the degree of impairment.
2. Does the patient have other conditions that limit the patient’s ability to participate in MRADLs at home?
If yes, what are the conditions?
I certify that, to the best of my knowledge, my answers to the above questions are accurate and supported by the
attached medical records.
Physician Signature:
Please return completed form to case management:
Fax Number:
1.336.659.2945 or
Address:
Blue Cross and Blue Shield of North Carolina
Attention: Care Management & Operations
PO Box 17509
Winston-Salem, NC 27116-7509
10/26/2005
PAGE 9-4
Chapter 9
Prior authorization requirements
9.5
Diagnostic imaging management program
AIM Specialty HealthSM (AIM) administers the diagnostic imaging management program for BCBSNC for the
management of outpatient, high-tech diagnostic imaging services for members covered under our Blue
Medicare HMOSM and Blue Medicare PPOSM Medicare Advantage plans. Participating providers arranging and
providing outpatient diagnostic imaging services for these members are required to comply with the
program’s prior authorization requirements for the services listed below when performed in a physician’s
office, outpatient department of a hospital, or freestanding imaging center:
• CT/CTA scans
• MRI/MRA scans
• Nuclear cardiology studies
• PET scans
• Echocardiography
Prior authorization can be obtained and/or confirmed online by logging onto Blue e,SM at blue-edi@bcbsnc.com
to access AIM’s Web-based application ProviderPortal.SM1 If you are not currently registered to use Blue e,SM you
will need to register online at bcbsnc.com. BCBSNC provides Blue eSM to providers free of charge. You may
also request prior authorization by calling AIM toll free at 1-866-455-8414.
Neither AIM nor BCBSNC will issue retro-certification. However, if the requested scan is of an urgent nature,
the ordering physician can request the certification within forty-eight (48) hours of the procedure.
Please note that unlike the diagnostic imaging management program for BCBSNC commercial membership,
prior authorization is required for all Blue Medicare HMOSM and Blue Medicare PPOSM members.
Services included
MRI/MRA, CT/CTA, PET, nuclear medicine, Echocardiography
Places of service included
Outpatient hospital, provider office, freestanding imaging center
(inpatient hospital), hospital observation and urgent care centers are
excluded).
Suppliers of the Technical
Component
*Providers (non-hospitals) must be accredited by a CMS-approved
organization in order to submit claims for the technical component of
certain high-tech diagnostic imaging services.
Prior authorization
via Blue eSM or by calling AIM at 1-866-455-8414
Member program participation
All Blue Medicare HMOSM and Blue Medicare PPOSM members.
Prior authorization CPT code list
bcbsnc.com/assets/common/pdfs/DIM-PPA-List.pdf
* Information about the accreditation process is available on the Medicare Provider-Supplier Enrollment page. Advanced Diagnostic
Imaging Accreditation, available at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/
index.html?redirect=/MedicareProviderSupEnroll/03_AdvancedDiagnosticImagingAccreditation.asp.
PAGE 9-5
Chapter 9
Prior authorization requirements
If you are not currently registered to use Blue e,SM you will need to register online at bcbsnc.com. BCBSNC
provides Blue eSM to providers free of charge.
If you currently access the AIM ProviderPortalSM1 to request prior authorization for BCBSNC members, you will
not need to make any changes or create an additional account. Blue Medicare HMOSM and Blue Medicare
PPOSM member information became available in the AIM ProviderPortalSM1 as of August 1, 2010.
Note: Blue e is available to access AIM’s Web-based application ProviderPortal, however Blue e currently
SM
SM1
SM
cannot be utilized to conduct other electronic transactions for the Blue Medicare HMO and Blue Medicare
PPOSM health care plans.
SM
Additional program details and training information is available on our Web site located at bcbsnc.com/
content/providers/dim-training.htm. If you have questions regarding the diagnostic imaging management
program please contact Network Management for assistance.
9.6
Protocol for potential organ transplant coverage
When a member is considered for any type of transplant, the following information needs to be submitted to
Care Management & Operations’ staff for review:
• Member’s name
• Member’s BCBSNC ID number
• Type of transplant being considered
• All transplants require prior authorization except corneal transplant
• Sufficient data to document diagnosis including a recent complete history and physical examination
• Treatment history
• Procedures/scans used to determine current stage of disease
• Reports of any specialty evaluations
• Copy of reports confirming diagnosis such as bone marrow examinations and/or biopsies
Upon receipt of the information, we will evaluate the records to determine coverage by BCBSNC.
Our process needs to be completed before a referral is scheduled to any transplant facility for transplant
evaluation. If the transplant is approved for coverage, BCBSNC will provide you with a list of our approved
hospitals for you and your patient to select a facility.
PAGE 9-6
Chapter 10
Pre-admission
certification
Chapter 10
Pre-admission certification
10.1
Pre-admission certification guidelines
All non-emergency hospital admissions require precertification by calling BCBSNC Care Management &
Operations department. The following information will be requested:
• Member’s name
• Member’s BCBSNC ID number
• Hospital name
• Admission date
• Admitting physician name
• Admitting diagnosis as well as any supportive or related information
(i.e., lab/x-ray results, symptoms, relevant social and medical history, prior treatment and other medical
conditions)
• Description of the proposed plan of treatment
(i.e., surgery, medical justification for any pre-operative days, lab/radiological testing, medications, need
for inpatient care vs. outpatient, admission orders if available, anticipated number of hospitalized days).
If a member is in the hospital longer than the anticipated initial length of stay, the Care Management &
Operations department will contact you for updates. The information requested will include the following:
• Current medical status
• Current treatment warranting hospitalization
• Anticipated length of stay
• Anticipated discharge plan, including home care or equipment
10.1.1 Non-emergency pre-admission certification
In non-emergency situations, the hospital will permit admissions of BCBSNC members to the hospital only
upon the written or verbal authorization of a participating physician who has medical staff membership and
admitting privileges at the hospital, and upon verification prior to admission that such admission is approved
by BCBSNC by telephoning a number supplied by BCBSNC to the hospital, or if the hospital is unable to
obtain such authorization by telephone, the hospital may permit the admission of the BCBSNC member
provided it verifies that such admission is approved by BCBSNC on the morning of the next business day. For
coverage and payment, the hospital agrees that in the event a physician is not designated as a participating
physician on the BCBSNC roster of participating providers, and the physician seeks to admit a BCBSNC
member to the hospital, the hospital shall contact BCBSNC prior to admission or treatment, to verify such
physician’s status and/or the referral before rendering provider services, unless it is an emergency medical
condition. The hospital shall not be entitled to compensation from BCBSNC for provider services rendered if
the hospital admits a BCBSNC member without following the procedures set forth herein or BCBSNC
determines that the admission was not medically necessary or not in compliance with BCBSNC policies,
procedures and guidelines.
This does not prevent the hospital from providing services to BCBSNC members admitted by non-contracting
physicians in non-emergency situations when such admission is not approved by BCBSNC.
PAGE 10-1
Chapter 10
Pre-admission certification
10.1.2 Emergency admissions
In cases of emergencies concerning BCBSNC members, the hospital is required to notify BCBSNC within
twenty-four (24) hours after admission of a BCBSNC member as an inpatient to the hospital, or by the end of
the first business day following the rendering of the emergency care, whichever is later, and to permit review
of the admission by a BCBSNC Medical Director or his or her designated representative. The hospital shall not
be entitled to compensation from BCBSNC for provider services rendered if the hospital fails to notify
BCBSNC of an admission of a BCBSNC member within the time period agreed to above or BCBSNC
determines that the admission was not a covered service, or medically necessary and/or not in compliance
with the terms of this agreement. The hospital’s obligation to notify BCBSNC shall be deemed to be satisfied
when an employee of the hospital notifies a representative of BCBSNC by telephone of the admission.
PAGE 10-2
Chapter 11
Case management
Chapter 11
Case management
11.1
Case management overview
Case management is designed for members
identified at risk for complex, chronic or rare
medical conditions or with complicated health care
needs. This program provides a nurse case manager
who can assist physicians and health care team
members to coordinate delivery of health care
services for members in the most effective manner.
Case managers are also available to assist members
in navigating through the health care system,
educate members regarding their medical condition,
and promote members’ compliance with the
physician directed treatment plan.
11.2
Case management programs
BCBSNC currently offers case management
programs for congestive heart failure, chronic
obstructive pulmonary disease, diabetes, and
complex, chronic diseases to eligible patients at no
cost to the patient.
11.2.1 Congestive Heart Failure (CHF) case
management programs
To assist with the management of high-risk CHF
patients, BCBSNC utilizes a telephonic nursing
management approach to identify problems early,
facilitate interventions, and avoid unnecessary
hospitalizations. Patients are assessed and may be
eligible for a telemonitoring system. This advanced
technology provides the opportunity for the patient
to report their data on a daily basis, including their
objective weight, via the telemonitoring device. If a
patient’s data exceeds the preset parameters, the
case manager will contact the patient for further
assessment. Case managers collaborate with the
patients’ managing physicians to promote effective
quality care.
Patients will be considered appropriate for the
monitoring program when the disease case
manager confirms the patient is high risk or has
one (1) or more of the following:
• The level of symptoms associated with heart
failure creates a severe functional limitation for
the patient.
• A lack of knowledge for self-management is
identified through assessment.
• A history of relatively rapid deterioration in
clinical status when heart failure symptoms
appear.
• Social isolation or other psychosocial barrier to
compliance that places the patient at increased
risk for complications. This includes inability to
obtain medications and/or follow diet and
recommended treatment plan.
• Presence of co-morbidities that are contributing
to the severity of symptoms and control of heart
failure clinical status such as COPD, diabetes,
and symptomatic CAD.
• Physician referral for the system supported by
the CHF diagnosis.
• Recommendation by the case manager involved
in the initial and ongoing assessment of the
patient to participate in the program.
11.2.2 Chronic Obstructive Pulmonary
Disease (COPD) case management
programs
To assist with the management of high-risk COPD
patients, BCBSNC utilizes a telephonic nursing
management approach to identify problems early,
facilitate interventions, and avoid unnecessary
hospitalizations. Patients are assessed and may be
eligibility for a telemonitoring system. This
advanced technology provides the opportunity for
the patient to report their data on a daily basis. The
case managers contact the patient for further
assessment if the reported data indicates a change
in the patient’s health status. Case managers
collaborate with the patients’ managing physicians
to promote effective quality care.
Patients will be considered appropriate for the
monitoring program when the case manager
confirms the patient is high risk or has one (1) or
more of the following:
• The level of symptoms associated with COPD
creates a severe functional limitation for the
patient.
PAGE 11-1
Chapter 11
Case management
• A lack of knowledge for self-management is
identified through assessment.
• A history of relatively rapid deterioration in
clinical status when COPD symptoms appear.
• Social isolation or other psychosocial barrier to
compliance that places the patient at increased
risk for complications. This includes inability to
obtain medications and/or follow diet and
recommended treatment plan.
• Presence of co-morbidities that are contributing
to the severity of symptoms and control of
chronic obstructive pulmonary disease clinical
status such as CHF, diabetes and symptomatic
CAD.
• Physician referral for the system supported by
the COPD diagnosis.
• Recommendation by the case manager involved
in the initial and ongoing assessment of the
patient to participate in the program.
11.2.3 Diabetes case management programs
To assist with the management of high-risk diabetes
patients, BCBSNC utilizes a telephonic nursing
management approach to identify problems early,
facilitate interventions, and avoid unnecessary
hospitalizations. Patient contact frequencies may
change based on individual needs to better
accommodate the patient’s health status, and/or in
collaboration with the patient’s physician to promote
effective quality care.
Patients will be considered appropriate for the
diabetes program when the case manager confirms
the patient is high risk or has one (1) or more of the
following:
• The level of symptoms associated with diabetes
creates a severe functional limitation for the
patient.
• A lack of knowledge for self-management is
identified through assessment.
• A history of relatively rapid deterioration in
clinical status when diabetes symptoms appear.
• Social isolation or other psychosocial barrier to
compliance that places the patient at increased
risk for complications. This includes inability to
obtain medications and/or follow diet and
recommended treatment plan.
• Presence of co-morbidities that are contributing
to the severity of symptoms and control of
diabetes clinical status such as COPD,
congestive heart failure, hypertension, obesity,
dyslipidemia, CVD, or neuropathy.
• Physician referral for the system supported by
the diabetes diagnosis.
• Recommendation by the disease case manager
involved in the initial and ongoing assessment
of the patient to participate in the program.
• Diabetes with concomitant cardiovascular disease.
11.2.4 Complex/chronic case management
programs
The complex/chronic case management program
utilizes telephonic monitoring to address the
patient’s health status. BCBSNC case managers
actively work with patients to identify those who are
at risk for deterioration of their condition. Contact
with the patient and the managing provider can
facilitate timely interventions, possibly avoiding
unnecessary hospitalizations and preventing
complications for the patient.
All case management program participants receive:
• Educational materials consistent with nationally
accepted, evidenced-based standards of
practice directed toward the specific disease
process and co-morbidities
• Telephone monitoring and education with
registered nurses
• Twenty-four (24) hour availability to educational
tapes and/or registered nurses through the
Telephone Learning Center (TLC) line,
toll free 1-888-215-4069
PAGE 11-2
Chapter 11
Case management
The BCBSNC case management programs are not
intended to be and should not be relied upon as a
substitute for appropriate medical care. In all cases,
BCBSNC patients should continue to see and follow
the recommendations of their treating doctors.
In the event the patient experiences severe
shortness of breath, chest pain or any other
urgent symptom, the patient should immediately
call their doctor, 911, or the emergency
services number in their area.
11.3
Referrals
To refer patients to one (1) of the case management
programs please call toll free 1-877-672-7647.
PAGE 11-3
Chapter 12
Medical guidelines
Chapter 12
Medical guidelines
12.1
Medical guidelines
Medical guidelines detail when certain medical services are considered medically necessary and are based on
Original Medicare National Coverage Determinations (NCD’s) and Local Coverage Determinations (LCD’s)
when available. The guidelines are reviewed and updated in response to changing CMS guidelines for
medical coverage or change in scientific literature if applicable.
As a Medicare Advantage (MA) plan, we are required by Centers for Medicare & Medicaid Services (CMS) to
provide, at a minimum, the same medical benefits to our members as Original Medicare. As an MA plan, we
cannot be more restrictive than Original Medicare, however, we are allowed to clarify or more fully explain
coverage in our policies. If Original Medicare does not have an NCD or LCD applicable to the service under
review, the MA plan can develop a guideline to define the plan’s coverage. Each individual’s unique, clinical
circumstances may be considered in light of current CMS guidelines and scientific literature.
Blue Medicare HMOSM and Blue Medicare PPOSM medical coverage policies are available for viewing online.
Providers can search for a policy to determine the medical necessity criteria needed for a coverage approval.
These policies are located on Blue Medicare HMOSM and Blue Medicare PPOSM providers’ page of
bcbsnc.com/content/providers/blue-medicare-providers/index.htm, available at: bcbsnc.com/content/
providers/blue-medicare-providers/medical-policies/index.htm.
Medical policies can be searched by alphabetical listing, as well as, a categorical listing to aid you in locating
a coverage policy. Questions relative to a specific procedure or precertification requirements may be obtained
by contacting Care Management & Operations at 1-800-296-9790.
PAGE 12-1
Chapter 13
Claims billing and
reimbursement
Attention!
ICD-10 Compliance required by October 1, 2015
Blue Cross and Blue Shield of North Carolina (BCBSNC) is preparing for
the health care industry’s conversion to the 10th version of the International
Classification of Diseases code set (ICD-10).
International Classification of Disease (ICD) is a standard set of diagnosis
and procedure codes maintained by The World Health Organization.
These codes are used to:
• Identify symptoms, conditions, problems, complaints or other reasons
for medical services or procedures being provided
• Translate written information in a patient’s chart into a form that can be
submitted electronically for reimbursement
• Identify provided procedures and services
• Establish current world mortality code for death records
The federal government mandated implementation of the new ICD-10
code set by October 1, 2015. The new code set provides more detail in
diagnosis and hospital procedure codes used by doctors, hospitals and
insurers.
In compliance with the United States Department of Health and Human
Services regulations, the industry-wide conversion to ICD-10 will occur on
October 1, 2015. All HIPAA-covered entities are required to use ICD-10
codes on all transactions, claims, authorizations, referral requests,
verification of benefits, and eligibility requests beginning on this date.
Providers should be aware that claims submitted with ICD-9 codes for
services provided on or after the compliance deadline will not be paid
by BCBSNC.
BCBSNC is taking the necessary steps to ensure that all of its systems and
processes will accommodate ICD-10 by the federal compliance date.
Additionally, this manual will be updated as part of our compliance review
process for 2015.
Providers are encouraged to visit BCBSNC’s Countdown to ICD-10 Compliance
Web site at bcbsnc.com/content/providers/legislative/icd10.htm for
additional information about ICD-10 and how they should prepare.
Chapter 13
Claims billing and reimbursement
Claims billing and reimbursement information
contained as part of this supplemental guide is
offered in conjunction with the claims billing and
reimbursement information contained in The Blue
Book,SM online manual for BCBSNC commercial
products. In the event that any information stated
within this supplemental guide conflicts with
information contained within The Blue Book,SM
online manual for BCBSNC commercial products,
providers should defer to this supplemental guide
when submitting claims for Blue Medicare HMOSM
and/or Blue Medicare PPOSM members.
13.1
General filing requirements
All Blue Medicare HMOSM and Blue Medicare PPOSM
claims must be filed directly to BCBSNC at our
Winston-Salem location and not to an intermediary,
or carrier such as CIGNA or Palmetto GBA. Claims
must be submitted within one hundred and eighty
(180) days of providing a service. Claims submitted
after one hundred and eighty (180) days will be
denied unless mitigating circumstances can be
documented.
BCBSNC is committed to processing claims
efficiently and promptly. Our imaging system
requires that the print on claims submitted be dark
and legible to enable accurate scanning. Claims
that are complete and accurate are normally
processed and paid within seven (7) to fourteen (14)
calendar days. A claim is not complete and accurate
and may be delayed or returned for revision when
the claim is difficult to interpret, incomplete, does
not follow usual and customary procedures, does
not comply with policies and procedures in this
manual, requires manual adjudication or review or is
received with a faint image. If filing on paper, please
submit OCR (optical character recognition) originals
and do not submit carbon copies or photocopies.
The following general claims filing requirements will
help ensure that your claims are complete and
accurate and will allow us to process and pay your
claims faster and more efficiently:
• For fastest claims processing, file electronically!
If you’re not already an electronic filer, please
visit Blue Medicare HMOSM and Blue Medicare
PPOSM provider resources for electronic
commerce on the Web at bcbsnc.com/providers/
blue-medicare-providers/electronic-commerce/
and find out how you can become an electronic
filer.
• Submit all claims within one hundred and eighty
(180) days.
• Do not submit medical records unless they have
been requested by BCBSNC.
• If BCBSNC is secondary and you need to submit
the primary payor Explanation of Payment (EOP)
with your paper claim, do not paste, tape or
staple the explanation of payment to the claim
form.
• Always verify the patient’s eligibility. Providers
with HealthTrio Connect can verify a member’s
eligibility and benefits immediately, and from
the convenience of their desktop computer.
Providers without HealthTrio Connect access
should call the BCBSNC provider line at
1-888-296-9790 or 1-336-774-5400. To find
out more about HealthTrio Connect, visit
electronic commerce on the Web at bcbsnc.com/
providers/blue-medicare-providers/electroniccommerce/.
• Always file claims with the correct member ID
number including the alpha prefix J and
member suffix. This information can be found
on the member’s ID card.
• File under the member’s given name, not his or
her nickname.
• Watch for inconsistencies between the diagnosis
and procedure code, sex and age of the patient.
• Use the appropriate provider/group NPI(s) that
matches the NPI(s) that is/are registered with
BCBSNC, for your health care business.
• If you are a paper claims filer that has not
applied or received an NPI, or if you have not
yet registered your NPI with BCBSNC, claims
should be reported with your provider number
(and group number if applicable) that’s been
assigned specifically for Blue Medicare HMOSM
and/or Blue Medicare PPOSM use.
PAGE 13-1
Chapter 13
Claims billing and reimbursement
‡ Remember that a distinct number may be
assigned for different specialties.
‡ Refer to your BCBSNC welcome letter to
distinguish the appropriate provider number
for each contracted specialty.
‡ If your provider number has changed, use
your new number for services provided on or
after the date your number changed.
‡ Terminated provider numbers are not valid for
services provided after the assigned end date.
• BCBSNC cannot correct claims when incorrect
information is submitted. Claims will be mailed
back.
13.1.1 Requirements for professional
CMS-1500 (02-12) Claim Form or
other similar forms
(Not to be considered an all inclusive list)
• All professional claims should be filed on a CMS1500 (02-12) Claim Form or other similar forms.
‡ If filing on paper, the red and white printed
version should be used.
• Once you have registered your NPI with
BCBSNC, you should include your NPI on each
subsequent claim submission to us.
‡ If you have not obtained or registered your
NPI with us, your BCBSNC assigned provider
number should be reported on each paper
claim submission.
‡ If your physician or provider number changes,
use your new number for services provided on
or after the date your number was changed.
‡ The tax ID number should correspond to the
physician or provider number filed in block 33.
• When submitting an accident diagnosis, include
the date that the accident occurred in block 14.
• Anesthesia claims are to be submitted using
anesthesia CPT codes as defined by the
American Society of Anesthesiologists. Claims
submitted using surgery codes instead of
anesthesiology codes will be returned requesting
anesthesiology codes.
• File supply charges using HCPCS health service
codes. If there is no suitable HCPCS code, give
a complete description of the supply in the
shaded supplemental section of field 24.
• If you are billing services for consecutive dates
(from and to dates), it is critical that the units are
accurately reported in block 24G.
• To ensure correct payment, include drug name,
NDC #, and dosage in field 24.
‡ Please note that the supplemental area of
field 24 is for the reporting of NDC codes.
Report the NDC qualifier “N4” in supplemental
field 24a followed by the NDC code and unit
information (UN = unit; GR = gram;
ML = milliliter; F2 = international unit).
Please note that fields 21 and 24e of the CMS-1500
Claim Form or other similar forms are designated for
diagnosis codes and pointers/reference numbers.
Only four (4) diagnosis codes may be entered into
block 24e. Any CMS-1500 Claim Form or other
similar forms submitted with more than four (4)
diagnosis codes or pointers/reference numbers will
be mailed back to the submitting provider.
• Claims will be rejected and mailed back to the
provider if the NPI number that is registered
with BCBSNC or the BCBSNC assigned provider
number is not listed on the Claim Form.
‡ Once a provider has registered their NPI
information with BCBSNC and BCBSNC has
confirmed receipt, claims should be reported
using the NPI only, and the provider’s use of
the BCBSNC assigned provider and/or group
number should be discontinued.
PAGE 13-2
Chapter 13
Claims billing and reimbursement
13.1.2 Requirements for institutional UB-04 Claim Forms
(Not to be considered an all inclusive list)
• All claims should be filed on a UB-04 Claim Form.
‡ If filing on paper, the red and white printed version should be used.
• The primary surgical procedure code must be listed in the principle procedure field locator 74.
‡ ICD-9 code required on inpatient claims when a procedure was performed.
‡ Field locator 74 should not be populated when reporting outpatient services.
• Please do not submit a second/duplicate claim without checking claim status first on HealthTrio Connect.
‡ Providers should allow thirty (30) days before inquiring on claim status via HealthTrio Connect.
.
‡ Please wait forty-five (45) days before checking claim status through the BCBSNC provider line.
PAGE 13-3
Chapter 13
Claims billing and reimbursement
13.2
Using the member’s ID for claims submission
When sending claims for services provided to Blue Medicare HMOSM and Blue Medicare PPOSM members, it’s
important that the member’s ID be included on the Claim Form (electronic and paper claims). The alpha-prefix
helps North Carolina providers identify what plan type a member has enrolled, but only the last alpha-character
of J is utilized for claims filing and claims processing. As example use the card image for John Doe below:
Sample Front of Card – HMO
Sample Back of Card – HMO
www.bcbsnc.com/member/
medicare
Enhanced
Member Name
<John Doe>
Member ID
<YPWJ1234567801>
Plan (80840)
Group No
Card Issued
Rx BIN
Rx PCN
Rx Group
North Carolina Hospitals or
physicians file claims to:
PO Box 17509
Winston-Salem, NC 27116
Alpha-prefixes that are unique to Blue
Medicare members –
Prefixes always in the letter J
XXXXXXXXXX
011100
mm-dd-yyyy
015905
HMONC
NCPARTD
$XX
Office Visit
$XX
ER/Urgent Care
$XX/day
Inpat Hospital
$XX
MHCD Outpt
XX%
Supplies/DME
Contract # H3449 005
MEDICARE
ADVANTAGE
HMO
Sample Front of Card – PPO
Hospitals or physicians outside
of North Carolina, file your claims
to your local BlueCross and/or
BlueShield Plan
Winston-Salem claims mailing
address for BCBSNC
Members: See your Evidence of Coverage
(EOC) for covered services
Medicare limiting charges
apply.
Alpha-prefixes that are unique to Blue
Medicare members –
Prefixes always in the letter J
XXXXXXXXXX
022100
mm-dd-yyyy
015905
PPONC
NCPARTD
Members send
correspondence to:
Blue Medicare HMO
PO Box 17509
Winston-Salem, NC 27116
SM
An independent licensees of the
Blue Cross and Blue Shield Association.
www.bcbsnc.com/member/
medicare
Enhanced
Plan (80840)
Group No
Card Issued
Rx BIN
Rx PCN
Rx Group
1-888-310-4110
1-888-451-9957
1-888-296-9790
1-800-266-6167
Sample Back of Card – PPO
#MVFi`ˆV>ÀiÊ**"
Member Name
<John Doe>
Member ID
<YPFJ1234567801>
Customer Service:
TTY/TDD:
Provider Line:
Mental Health/SA:
$XX
Office Visit
$XX
ER/Urgent Care
$XX/day
Inpat Hospital
$XX
MHCD Outpt
XX%
Out of Network
Contract # H3404 001
MA
PPO
North Carolina Hospitals or
physicians file claims to:
PO Box 17509
Winston-Salem, NC 27116
Customer Service:
TTY/TDD:
Provider Line:
Mental Health/SA:
Members send
correspondence to:
Blue Medicare HMO
PO Box 17509
Winston-Salem, NC 27116
Hospitals or physicians outside
of North Carolina, file your claims
to your local BlueCross and/or
Winston-Salem claims
BlueShield Plan
mailing address for BCBSNC
Members: See your Evidence of Coverage
(EOC) for covered services
1-877-494-7647
1-888-451-9957
1-888-296-9790
1-800-266-6167
SM
An independent licensees of the
Blue Cross and Blue Shield Association.
MEDICARE ADVANTAGE
• The above sample card displays the member ID for John Doe as: < YPFJ12345678-01 >
• The alpha-prefix of YPF identifies the member’s plan type but is not necessary for claims submission
(YPW = HMO and YPF = PPO).
• The letter J is always the last alpha-character of a Blue Medicare HMOSM or Blue Medicare PPOSM
member’s ID. It is used in conjunction with the member’s identifying numeric code and is essential for
claims routing and processing.
• The numbers 12345678 are part of the member’s identifying numeric code – as part of our on-going
efforts to help protect member’s privacy, BCBSNC assigns member identification codes by use of
randomly selected numbers instead of using social security numbers.
• The numbers 01 comprise the member’s numeric suffix, identifying a specific member.
To submit claims for Blue Medicare members always include the member’s alpha-prefix of J, the member’s
numeric code and the member’s two (2) digit suffix. As example, J1234567801 would be reported on a claim
submission for member John Doe.
PAGE 13-4
Chapter 13
Claims billing and reimbursement
13.3
Electronic claims filing and
acknowledgement
The best way to submit claims to BCBSNC is
electronically. Electronic claims process faster than
paper claims and save on administrative expense for
your health care business. For more information
about electronic claims filing and other Electronic
Data Interchange (EDI) capabilities, please refer to
electronic commerce on the Web at bcbsnc.com/
providers/edi/.
EDI Services supports applications for the electronic
exchange of health care claims, remittance,
enrollment and inquiries and responses. EDI
Services also provides support for health care
providers and clearinghouses that conduct business
electronically. If you are already submitting
electronically, and need assistance, contact EDI
Services through the BCBSNC provider line at
1-888-296-9790.
Our procedures are designed to have claims, which
are complete and accurate, processed within
twenty-four (24) to thirty-six (36) hours upon claims
receipt and provide an EDI acknowledgment report
to indicate the status of your claim submission.
Please note that payments and Explanation of
Payments (EOPs) are based on financial processing
schedules. Providers are expected to work their
rejected claims report so claims can be resent to
BCBSNC and accepted for payment.
Requests for service
Health care providers or clearinghouses electing to
transmit electronic transactions directly with
BCBSNC must sign a trading partner agreement and
submit the original copy to EDI Services. The trading
partner agreement establishes the legal relationship
between BCBSNC and the trading partner. Health
care providers, who submit their transmissions
indirectly to BCBSNC via a clearinghouse, do not
need to complete the trading partner agreement
but are required to fill out an electronic connectivity
form. The following procedures should be followed
to obtain the electronic connectivity form:
• The health care provider calls BCBSNC
customer services at 1-800-942-5695 and
makes the request to be set up for electronic
submission. The health care provider will need
to supply a contact name, phone number and
email address.
• An email containing an electronic form will then
be emailed to the health care provider, which
can be filled out electronically. The form will
then need to be printed, must be signed and
the hard copy returned to BCBSNC EDI services
by mail.
• Once the form is received containing all the
required information, the health care provider
will be set up in the BCBSNC system to submit
electronically.
• After successful set up, the provider will be
mailed a confirmation letter containing their
payor ID, user ID, password and instructions for
claims filing.
• The health care provider must call BCBSNC EDI
services once the confirmation letter is received,
and an EDI specialist will go over the instructions
with the provider and answer any questions at
that time. The health care provider should allow
eight to ten (8-10) business days to complete
the set up process.
Acceptable file type:
• ANSI 837 version 4010A1 professional and
institutional implementation 2b (used by
Medicare)
Hardware requirements:
• Hayes compatible modem
• 9600 baud rate or higher
• Xmodem, Zmodem or Kermit protocols
Filing requirements:
• Once a transmission is established, all claims
(including new claims, additions, corrections and
2nd notices) are to be submitted via EDI
• Coordination of benefits and office notes are to
be filed on paper
PAGE 13-5
Chapter 13
Claims billing and reimbursement
13.3.1 Sample electronic claims acknowledgement report
Summary section
Rejected status
Accepted
Submitted
BBS ID
Provider
ID number
Total
claims
Total
lines
Map
errors
Load
errors
Denied
claims
Pended
claims
Accepted
claims
A
B
C
D
E
F
G
H
I
A: Submitter identifier
B: Provider’s unique identifier as defined by BCBSNC
C: Number of claims submitted per provider
D: Number of service lines submitted per provider
E: Number of claims failed in the existence of data check
F: Number of claims failed in the data cross-reference validation
G: Number of claims denied
H: Number of claims pended
I: Number of claims accepted for payments C = E + F + G + H + I
Detailed rejected section
Original claim number
BCBSNC claim number
Error type
Error description
1
2
3
4
1: Invoice number or patient account number as provided by the submitter
2: Blue Medicare claim number
3: Relates to the summary section under rejected status and can be one of three possibilities: map, load or denied
4: Reason why a claim was rejected
13.4
Blue Medicare claims mailing addresses
Mailing addresses – BCBSNC Blue Medicare HMO and Blue Medicare PPO
SM
Main mailing address
FedEx, UPS and 4th class
BCBSNC
PO Box 17509
Winston-Salem, NC 27116-7509
BCBSNC
PO Box 17509
Winston-Salem, NC 27116-7509
SM
Claims sent in error to BCBSNC for Blue Medicare HMOSM and Blue Medicare PPOSM members (filed
electronically or by mail) will be returned to the submitting provider, which will result in delayed payments.
PAGE 13-6
Chapter 13
Claims billing and reimbursement
13.5
Claim filing time limitations
Participating providers agree to complete and
submit a claim to BCBSNC for services and/or
supplies provided to Blue Medicare HMOSM and/or
Blue Medicare PPOSM members.
The claim should include all information reasonably
required by BCBSNC to determine benefits
according to the member’s benefit plan and the
provider’s typical charge to most patients for the
service and/or supply.
The claim should be submitted only after all complete
services have been provided, with the exception of
continuous care services or ongoing services.
Claims must be submitted within one hundred and
eighty (180) days of providing the service.
Unless qualifying as an eligible exception under
guidance of the Centers for Medicare & Medicaid
Services (CMS), corrected claims must be submitted
no later than one (1) year (twelve [12] months) from
the date of service.
File claims for rental services monthly (after thirty
[30] consecutive days of rental), or at the time the
rental is determined to no longer be medically
necessary, whichever is first.
13.6
Verifying claim status
You can inquire about the status of a claim in one (1)
of the following ways:
• Check claim status from your desk top computer
using HealthTrio Connect. Just make an inquiry
and HealthTrio Connect enables users to verify
the status of Blue Medicare claims. Providers
without HealthTrio Connect access can call the
BCBSNC provider line at 1-888-296-9790. To
find out more about HealthTrio Connect, visit
electronic commerce on the Web at bcbsnc.com.
• Complete a provider claim inquiry form (see
Chapter 24, Forms) and fax it to BCBSNC
Customer Service Department, 1-336-659-2963.
Please note that we will be able to research claims
and provide better service to you if you wait until
after forty-five (45) days from a claims submission
date before initiating an inquiry or resubmitting a
previously filed claim. Routinely refiling all claims at
the end of the month may cause extra paperwork
for everyone involved. We advise all offices to file
claims at least once per week, post payments to
your accounts within three working days and deposit
your checks daily. Also, we would advise you to
generate a listing of past due claims at least
quarterly. If you need to check on the status on
more than five (5) claims at a time, please complete
a provider claims inquiry form.
13.7
Electronic Funds Transfer (EFT)
Blue Cross and Blue Shield of North Carolina
(BCBSNC) Financial Services offers EFT for claim
payments from BCBSNC to a contracted health care
provider’s bank account. Generally, EFT funds are
accessible by providers sooner than remittances
received through a traditional process of paper
checks deposited by the provider. EFT enrollment
forms can be accessed via Blue e.SM Health care
providers that do not have access to Blue e,SM can
access the form via the Web site at bcbsnc.com.
The following outlines the process for setup of an
EFT payment to a provider’s bank account.
• Health care providers are required to submit:
‡ Copy of a voided check; (an account
verification letter on blank letterhead is also
acceptable)
‡ Completed Electronic Funds Transfer
Authorization form
• The completed Electronic Funds Transfer
Authorization form, along with the voided check
copy, must be either faxed or mailed to:
Fax Number: 1-919-765-7063
(Contact Phone Number: 1-919-765-2293)
BCBSNC Financial Services
Attention: Electronic Funds Transfer
PO Box 2291
Durham, NC 27702-2291
PAGE 13-7
Chapter 13
Claims billing and reimbursement
Please note:
• A separate Electronic Funds Transfer
Authorization is required for each providergroup number to be set up for EFT.
•A provider-group number may be associated to
only one (1) bank account number.
•BCBSNC Financial Services verifies the bank
name and the bank transit or routing number.
•After verification, EFT status is loaded to the
BCBSNC claims system. The average time to set
up a provider-group for EFT remittance is five (5)
days from receipt of all documentation by
BCBSNC.
• All EFT payments are made at the providergroup number/NPI level vs. payments to
individual providers, unless payments are being
directed to a solo practitioner.
13.8
Reimbursement for services
Participating physicians agree to bill only BCBSNC
for all covered services for BCBSNC members,
collecting only appropriate copayments or
coinsurance from the member. BCBSNC members
are directly obligated only for the copayment
amounts indicated on their member card (and in
their certificate of coverage or evidence of
coverage), payment for noncovered services for
which BCBSNC issued an organization determination
denying coverage before the services are rendered,
and payment for services after the expiration date of
the member’s coverage. The physician should not
collect any deposits and does not have any other
recourse against a BCBSNC member for covered or
noncovered services.
In the event that the participating physician provides
services which are not covered by the Plan, the
provider will, prior to the provision of such
noncovered services, confirm that the member has
received an organization determination from
BCBSNC denying coverage. BCBSNC shall make
the relevant terms and conditions of each Plan
reasonably available to participating physicians.
If a participating physician is not sure whether a
service is covered under a member’s certificate of
coverage, he or she may call the provider line at
1-888-296-9790 or 1-336-774-5400. The
participating physician may only bill a member
directly for noncovered services when BCBSNC has
issued an organization determination informing the
member that the services are not covered before
the services are rendered.
13.8.1 Service edits
BCBSNC reserves the right to implement service
edits to apply correct coding guidelines for CPT,
HCPCS, and ICD-9 diagnosis and procedure codes.
Service edits are in place to enforce and assist in a
consistent claim review process. The coding edits
reflect BCBSNC Medical Coverage Guidelines,
benefit plans, and/or other BCBSNC policies.
Unbundling, mutually exclusive procedures,
duplicate, obsolete, or invalid codes are identified
through the use of coding edits.
13.9
Amounts billable to members
• Applicable copayments may be collected at the
time service is rendered. Copayment amounts
are indicated on the members Blue Medicare ID
card.
• Applicable coinsurance and deductible amounts
may be collected from Blue Medicare members
only after the provider has received the
Notification of Payment (NOP) or Explanation of
Payment (EOP).
• Following are examples of services that may be
eligible for the collection of copayment and/or
coinsurance:
‡ Office visit
‡ Office visit with lab and/or x-ray
‡ Office based surgery (when performed in the
office and appropriate to be billed in
conjunction with an office visit – please refer to
current CPT professional edition coding).
‡ ER visit
‡ Outpatient services
PAGE 13-8
Chapter 13
Claims billing and reimbursement
‡ Inpatient admission
‡ Noncovered services may be collected, only if
they meet the criteria outlined in the
instruction of the hold harmless policy (see
Chapter 13.9.3 for details).
‡ Any amounts collected erroneously by you
from a member for any reason shall be
refunded to the member within forty-five (45)
days of the receipt of the notification/
explanation of payment from BCBSNC or your
discovery of the error.
13.9.1 Items for which providers cannot bill
members
Except for any applicable copayment, coinsurance
and/or deductible amounts, providers may not
collect any payments from members for covered
services or for noncovered services for which
BCBSNC did not issue an organization determination
of noncoverage before the services were rendered.
For covered services, providers may not balance bill
Blue Medicare members for the difference between
billed charges and the amount allowed by BCBSNC,
as set forth in the agreement. For noncovered
services for which BCBSNC did not issue an
organization determination denying coverage
before the services were rendered, providers may
not balance bill Blue Medicare members for the
difference between billed charges and any
applicable copayment, coinsurance, and/or
deductible amounts. Any such differences are
considered contractual adjustments and are not
billable to members or BCBSNC.
Providers may not bill or otherwise hold members or
BCBSNC responsible for payment for services,
which are deemed by BCBSNC to be out of
compliance with BCBSNC utilization and
management programs and policies or medical
necessity criteria or are otherwise noncovered.
Providers may not seek payment from either
members or BCBSNC if a proper claim is not
submitted to BCBSNC within one hundred and
eighty (180) days of the date a service is rendered.
13.9.2 Billing members for noncovered
services
From time to time a provider may be asked to
provide services to members that are not covered
by their benefit plan with BCBSNC. A provider can
only bill a member for such services when the
member has received an organization determination
from BCBSNC denying coverage before the
services are rendered.
A provider cannot use an advanced beneficiary
notice or similar type of waiver or release that
purports to obligate the member to pay the
provider for the noncovered services.
Providers may inquire about eligibility of services by
calling the customer service number on the back of
the member’s ID card or by calling the provider line
at 1-888-296-9790 or 1-336-774-5400.
Confirmation of benefit eligibility does not
guarantee payment as other factors may affect
payment (e.g. BCBSNC utilization and management
programs and policies or medical necessity criteria).
13.9.3 Hold harmless policy
The member will not be held financially responsible
for the cost of covered services except for any
applicable copayment, coinsurance, or deductible if
ALL of the following are true:
• The member has followed the guidelines of the
Plan.
• The PCP or participating specialist fails to obtain
precertification with Blue Medicare HMOSM and
Blue Medicare PPOSM health care services
department for those covered services which
require precertification.
• The non-precertified covered services have
already been rendered.
The member will not be held financially responsible
for the cost of noncovered services except for any
applicable copayment, coinsurance, or deductible if
the noncovered services are rendered before the
member receives an organization determination
from BCBSNC denying coverage.
PAGE 13-9
Chapter 13
Claims billing and reimbursement
In either instance, the participating provider will be
advised that they must write-off the cost of the noncertified or noncovered services, and hold the
member financially harmless according to contract
provisions.
Ancillary services provided in conjunction with
non-precertified services are also not payable by the
Plan unless the ancillary provider is a nonparticipating
provider.
This policy will also apply when Plan is the secondary
payer of claims.
Members will be held responsible for non-certified
services when the member receives an organization
determination from BCBSNC denying coverage
before the services are rendered.
13.9.3.1 CMS-required provisions regarding the
protection of members eligible for both
Medicare and Medicaid “dual eligibles”
Federal legislation has made changes to the
Medicare program. Current network provider
agreements; in the section entitled “hold harmless”
incorporates certain CMS-required provisions
regarding the protection of members. Changes to
CMS’s requirements that became effective
January 1, 2010 resulted in our obligation to amend
our contracts to incorporate specific hold harmless
provisions as they relate to members that are dually
eligible for both Medicare and Medicaid. The
amendment is as follows:
The section entitled “Hold Harmless” is hereby
amended to include the following:
• Members eligible for Medicaid. Providers agree
that members eligible for both Medicare and
Medicaid “dual eligibles” will not be held liable
for Medicare Part A and B cost sharing when the
state is responsible for paying such amounts.
Provider agrees to accept the MA plan payment
as payment in full or bill the appropriate state
Medicaid agency for such amounts.
13.9.3.2 CMS-required provisions regarding the
protection of members who receive
noncovered services or supplies from a
participating provider.
Regulatory guidance issued by CMS resulted in our
obligation to amend our contracts to incorporate
specific hold harmless provisions as they relate to
the provision of noncovered services.
Section 2.2, Hold Harmless is hereby amended as
follows:
• Provider agrees that except for applicable
deductibles, copayments or coinsurance, and
except as otherwise required by law, in no
event, including but not limited to non-payment,
BCBSNC insolvency, or breach of this agreement,
shall provider bill, charge, collect a deposit
from, seek compensation, remuneration or
reimbursement from, or have any direct or
indirect recourse for covered services against a
BCBSNC member, a person acting on such
BCBSNC member’s behalf, or a third party
including but not limited to subrogation and
Workers’ Compensation carriers. Provider agrees
that it is the provider’s obligation, to collect
applicable BCBSNC member deductibles,
copayment, and coinsurance, if any, as well as
fees for noncovered services. Provider may not
collect fees for noncovered services or supplies
unless, before services are rendered or supplies
are provided, the BCBSNC member has received
an organization determination from BCBSNC
informing the member that the specific services
to be rendered and/or supplies to be provided
are not covered by his or her health benefits plan.
PAGE 13-10
Chapter 13
Claims billing and reimbursement
13.10
Coordination of Benefits (COB)
Coordination of Benefits (COB) is an approach used
by health plans and health insurers to divide the
obligation for payment of health care expenses. It is
not uncommon to encounter patients who are
covered under more than one (1) health plan.
Patients could be receiving coverage from sources
that could include a large private insurer, another
managed care plan, Medicaid, a self-insured plan or
a COBRA-continued plan.
In the event a benefit is covered by both BCBSNC
and another policy or plan, BCBSNC will coordinate
benefits and benefit payments with such plans or
policies, whether or not a claim is made for benefits.
• If the member is aged sixty-five (65) or older
and have coverage under an employer group
health plan either through his/her own current
employment or the employment of a spouse,
(including COBRA coverage), that Plan will be
the primary payer. This rule applies to the health
plans of employers with twenty (20) or more
employees. BCBSNC will be the secondary payer.
• If the member is under age sixty-five (65) and
entitled to Medicare due to a disability (other
than end stage renal disease) and has coverage
under a large employer group plan, either
through his/her own employment or the
employment of a family member, that Plan will
be the primary payer. BCBSNC will be the
secondary payer.
• If automobile medical or no-fault or liability
insurance is available to you, in the event of an
accident, then that carrier will be the primary
payer.
• If the member is eligible for Medicare solely on
the basis of End Stage Renal Disease (ESRD)
and is covered under an employer group plan,
that Plan will be the primary payer for the first
thirty (30) months after becoming eligible for
Medicare.
• Workers’ Compensation for treatment of a workrelated illness or injury or veteran’s benefits for
treatment of service-connected disability or under
the Federal Black Lung Program would be primary.
• Coverage through Medicaid or through the
Tricare for Life program will be coordinated
based on Medicare rules.
BCBSNC uses the same guidelines in these cases as
does Medicare. Because of this, we do ask the
member about other insurance they may have. If the
member has other insurance, they are asked to help
us obtain payment from the other insurer by promptly
providing any information we may request.
BCBSNC will assist you with information concerning
a patient’s coverage. In addition, BCBSNC will assist
you by working directly with patients and their
primary insurance sources to ensure that you, the
provider, are entitled to the maximum benefit
available. Consistent with our contractual obligations,
it is also our intent to maximize a member’s benefit
under our Plan. Therefore, if a patient’s primary
insurance issues a benefits payment that is greater
than the BCBSNC copayment, the copayment will
be waived.
13.11
Workers’ Compensation claims
If a Blue Medicare member sustains an injury while
at work, it is important that the member follow
BCBSNC’s rules and procedures in order to be
eligible for Blue Medicare HMOSM or Blue Medicare
PPOSM benefits, should Workers’ Compensation deny
the claim. All applicable authorizations must be
obtained under BCBSNC guidelines in order for
Blue Medicare HMOSM or Blue Medicare PPOSM
benefits to be payable in the event Workers’
Compensation denies the claim. Failure to follow
BCBSNC policies will release BCBSNC from any
payment responsibility.
If you are informed or have reason to believe a
patient has sustained an injury at work, please call
BCBSNC to notify us. We may need to inform other
providers so they may also file for benefits under
Workers’ Compensation.
For further details on governing rules, or assistance
with COB, Medicare or Workers’ Compensation,
please contact BCBSNC customer services department.
PAGE 13-11
Chapter 13
Claims billing and reimbursement
13.12
Subrogation
A Blue Medicare member may incur medical
expenses due to injuries suffered in an accident. The
accident may have been caused by the alleged
negligence or misconduct of another person. If so,
the member may have a claim against that person
for payment of medical bills.
Subrogation means the right of BCBSNC to pursue
the claim for medical expenses against the other
person, so that the other person (or their insurer)
pays for the member’s medical expenses.
Subrogation of benefits is allowed. Therefore,
BCBSNC has the right to pursue and recover from a
claim that may have been filed against another
person.
If the member has a claim against another person,
BCBSNC will be subrogated to the right of recovery
the member has against that person. Therefore,
BCBSNC will deny payment of all medical bills
pending settlement of the claim against the other
person. If there is not a prompt settlement, BCBSNC
will conditionally pay the medical bills and require
that the member reimburse BCBSNC. For this
purpose, the definition of prompt will be one
hundred and twenty (120) days after the earlier of
the following:
• The date a claim is filed with an insurer or a lien
is filed against a potential liability settlement; or
the date the service was furnished or, in the case
of inpatient hospital services, the date of
discharge.
BCBSNC’s right of subrogation will not exceed the
lesser of the following:
• The amount of benefits paid by BCBSNC; or the
portion of the recovery attributable to covered
medical expenses.
If the portion of the recovery that is attributable to
medical expenses is not specified in a judgment or
settlement, then one-third (1/3) of the net recovery
shall be deemed to be the portion of the recovery
attributable to medical expenses. Net recovery shall
mean the total amount of the recovery less
reasonable attorneys’ fees and expenses incurred in
obtaining the recovery.
13.13
Claims reimbursement disputes
In the event an error is found on an Explanation of
Payment (EOP) on behalf of the provider; a request
for correction may be initiated either via telephone
or in writing. To request a review for correction in
writing, the following information must be included:
• Letter of explanation relative to any error in the
processing of claim
• Copy of the original claim
• Copy of corresponding EOP with the claim in
question circled
• Requests for correction should be mailed to the
following address:
Blue Cross and Blue Shield of North Carolina
PO Box 17509
Winston-Salem, NC 27116
To request a review for correction via telephone,
please contact BCBSNC Provider Line at
1-888-296-9790 and be prepared to give the
following information:
• Patient name and Blue Medicare member ID
• Date of service
• Claim number
• Explanation of any suspected error
13.14
Pricing policy for Part B procedure/
service codes (applicable to all PPO
and HMO products)
Effective June 1, 2005, updated 08/23/2010 and
revised 09/09/2013.
The following policy applies to BCBSNC’s payment
to contracted providers for procedure/service codes
billed on a CMS-1500 (Part B Medicare) Claim Form
or other similar forms. When services billed on
UB-04 forms are contracted using FFS rates, this
procedure would also apply.
PAGE 13-12
Chapter 13
Claims billing and reimbursement
General pricing policy
• When new codes are published, or updates to
existing codes occur, and an external pricing
source exists for such codes, BCBSNC will
implement such pricing by no later than April 1st
of each year or within thirty (30) days of source
publication. Such updates and new pricing will
apply for all dates of services on or after the
source pricing effective date, but only for claims
received after the date of BCBSNC’s
implementation of the update/new pricing.
BCBSNC is not required to make retroactive
pricing adjustments for claims received prior to
BCBSNC’s implementation date. Updates will
be made using the following procedure:
‡ If NC Medicare pricing is available, the most
current NC Medicare pricing available will be
applied to that code.
‡ If NC Medicare pricing is unavailable,
BCBSNC will apply the most current Medicare
allowable pricing if available, using the same
methodology described above and the
following external resources:
~ Burgess Reimbursement System
~ Optum Ingenix
~ Palmetto GBA (www.palmettogba.com)
~ CIGNA Government Services
(www.cgsmedicare.com) for DMEPOS
‡ For durable medical equipment, the CIGNA
Government Services DME Jurisdiction C fee
schedule will be used in place of the above
referenced external sources.
Source: www.cignagovernmentservices.com/
jc/coverage/fees/index.html
‡ BCBSNC reimburses the lesser of your charge
or the applicable pricing.
‡ Nothing in this policy will obligate BCBSNC to
make payment on a claim for a service or supply
that is not covered under the terms of the
applicable benefit plan. Furthermore, the
presence of a code and allowable on your sample
fee schedule does not guarantee payment.
External source pricing
All references in this procedure to external source
pricing refer to the following:
• NC Medicare (available at www.cms.hhs.gov)
• CIGNA Medicare allowables (available at
www.cignagovernmentservices.com)
In the event that the names of such external source
pricing change (e.g. a new Medicare intermediary is
selected), references in this procedure will be
deemed to refer to the updated names. In the event
that new external source pricing generally acceptable
in the industry and acceptable to BCBSNC becomes
available, such external source pricing may be
incorporated by BCBSNC into this procedure.
13.14.1 Prescription drug CPT and HCPCS codes
These codes are priced following CMS guidelines
and do not include those services covered under the
CMS Part D program. Codes not falling under a
separate prospective payment system will be based
on a percentage of Average Sales Price (ASP) or
average wholesale price, depending on the drug.
Resources used to arrive at rates include Web sites
for CMS and CIGNA as well as Red Book References.
For HIT services, drugs covered by Medicare will be
based on the current year DME Regional Carrier
priced AWP if infused through DME per Section
303(b) of the Medicare Modernization Act.
Infused drugs not covered by Medicare will be
based on Average Wholesale Price (AWP) listed in
the most recently published and available edition of
the Medicare Economics Red Book Guide to
Pharmaceutical Prices as of the date of service.
BCBSNC will require the name and dose of the drug
provided. Parenteral and enteral nutrition will be
based on the PEN rates contained in the DME POS
fee schedule published quarterly by the DME Regional
Carrier (CIGNA government services at this time).
Drugs not assigned a specific HCPCS codes by CMS
will be priced using the Not Otherwise Classified
(NOC) file as published by the Part B fiscal
intermediary (CIGNA Medicare at this time).
PAGE 13-13
Chapter 13
Claims billing and reimbursement
13.14.2 Policy on payment for remaining codes
13.14.3 Policy on payment based on charges
Procedure/service codes that remain unpriced after
each application of the above procedure will be
paid in the interim at the lesser of the provider’s
charge or a reasonable charge established by
BCBSNC using a methodology that is applied to
comparable providers for similar services. BCBSNC’s
methodology is based on several factors including
payment guidelines as published in the BCBSNC
provider manual. Under these guidelines, some
procedures charged separately by the provider may
be combined into one procedure for reimbursement
purposes.
If a general code (e.g. 21499, unlisted musculoskeletal
procedure, head) or unlisted code is filed because a
code specific to the service or procedure is
nonexistent, BCBSNC will assign a fee to the service
which will be the lesser of the provider’s charge or a
reasonable charge established by BCBSNC using a
methodology which is applied to comparable
providers for similar services under a similar health
benefit plan. BCBSNC may use clinical judgment to
make these determinations, and may use medical
records to determine the exact services rendered.
BCBSNC may use clinical judgment to make these
determinations, and may use medical records to
determine the exact services rendered. For codes
that BCBSNC approves as clinically necessary, have
no price applied using any of the procedures
described above, and are billed as less than $100,
BCBSNC will pay 50% of the provider’s billed charge.
Durable medical equipment claims or medical or
surgical supply claims that are filed under general or
unlisted codes must include the applicable
manufacturer’s invoice and will be paid at the
invoice price. BCBSNC will not pay more than 100%
of the respective charge for these claims.
If a general or unlisted code is filed despite the
existence of a code specific to the service or
procedure, BCBSNC will apply the more specific
code to determine payment under BCBSNC’s
applicable reimbursement policies.
BCBSNC’s assignment of a fee for a given general or
unlisted code does not preclude BCBSNC from
assigning a different fee for subsequent service or
procedure under the same code. Fees for these
services may need to be changed based on new or
additional information that becomes available
regarding the service in question or other similar
services.
PAGE 13-14
Chapter 13
Claims billing and reimbursement
13.15
What is not covered under the medical benefit
This is a list of general exclusions. In some cases, a member’s benefit plan may cover some of these services
or have additional exclusions. Please call the BCBSNC Provider Line at 1-888-296-9790 or 1-336-774-5400
to verify benefit coverage.
• Abortion: Any abortion which is considered illegal under laws which govern the state in which BCBSNC is
licensed, and any abortion which is not covered by Medicare.
• Acupuncture: Unless performed by BCBSNC-approved physician.
• Allergy testing: Skin titration (RINKEL method); cytotoxicity testing (Bryan’s test); MAST testing; urine
autoinjections; subcutaneous or sublingual provocative and neutralization testing for allergies.
• Behavioral disorders: Services, treatment or diagnostic testing related to behavioral (conduct) problems
or behavioral training.
• Chiropractic care: Except for manual manipulation of the spine for subluxation, x-rays ordered by a
chiropractor to diagnose subluxation of the spine.
• Circumcision: For non-medically indicated reasons after one (1) month of age.
• Clinical trials: Services not covered under Original Medicare, and not covered by BCBSNC.
• Custodial care: The provision of room and board, nursing care, and personal care designed to assist
member in the activities of daily living; or such other care which is provided to member who, in the
opinion of BCBSNC, has reached the maximum level of physical or mental function and will not make
further significant improvement. Custodial care rendered in the home and adult day care facilities.
• Dental services: All dental services, unless otherwise specified, including bridges, dentures, crowns,
treatment for periodontal disease, dental root form implants, root canals, orthodontic appliances or any
other treatment primarily to align teeth, appliances, orthognathic surgery (unless deemed medically
necessary) or extraction of wisdom teeth except as provided in the member certificate of coverage;
treatment for teeth which are chipped or broken from biting or chewing; and anesthesia for dental
procedures, except as provided in the member certificate of coverage.
• Foot care: Routine foot care including corn and callous removal; nail trimming; and other hygienic or
maintenance care; cleaning, soaking and skin cream application for ambulatory and bed-confined patients
unless covered by Original Medicare.
• Hospice: Not covered by BCBSNC. A Medicare beneficiary with Medicare Part A, may elect traditional
Medicare hospice coverage (through traditional Medicare, not BCBSNC) and can decide to keep Blue
Medicare coverage for services not related to the terminal illness or elect traditional Medicare coverage
for everything by disenrolling from Blue Medicare. Claims for all hospice related services must be billed to
traditional Medicare, not BCBSNC.
Note: Even though traditional Medicare covers the services related to the terminal illness, BCBSNC will
provide the member with a listing of Medicare certified hospice providers in their area.
• Lenses: Contact lenses or the fitting thereof, except for the first pair of lenses or eyeglasses following a
cataract operation (this may include contact lens or placement of intraocular lens).
• Long-term skilled care services: Skilled care services in the home that do not qualify as part-time or
intermittent, as defined by Medicare, or skilled care services in a skilled nursing facility or unit, or a subacute facility or unit, for a period exceeding one hundred (100) days per benefit period (beginning with
the first day a member received these services).
• Naturopathy
PAGE 13-15
Chapter 13
Claims billing and reimbursement
• Obesity: Services and drugs in connection with obesity, including but not limited to, surgical procedures
such as gastric bypass surgery, balloon insertion and removal; and experimental services and complications.
Services specifically used for treatment of obesity, except other services and treatments within standard
medical practice policies or covered by Original Medicare and which are authorized and approved by
BCBSNC.
• Occupational injury or sickness: The cost of services for any injury which occurs in the work place, or a
sickness which occurs as a result of employment, normally covered under Workers’ Compensation or other
employer’s liability laws. Should a member have the cost of services denied by one (1) of the above
insurance programs, BCBSNC will consider payment of covered services. BCBSNC will not cover the cost
of services that were denied by the above insurance programs for failure to meet administrative or filing
requirements.
• Organ transplants: Experimental/investigational transplants. Combined kidney and liver transplant is not
covered. Coverage is limited to Medicare covered services. Pancreas transplantation for diabetic patients
who have not experienced end stage renal failure secondary to diabetes continues to be excluded from
Medicare.
• Orthopedic shoes: Unless covered by Medicare (for individuals with diabetic foot disease) or part of a leg
brace and included in the cost of the leg brace.
• Orthotics: Foot orthotics, i.e., custom shoes or custom inserts for shoes or boots except as covered by
Original Medicare or as specified in the member certificate of coverage.
• Personal comfort or convenience items, convenience fees, household fixtures and equipment and
member refused items and services: Chairs, personal comfort or convenience items such as household
fixtures and equipment or related services and supplies not directly related to the care of the member,
including but not limited to, guest meals and accommodations; telephone charges; travel expenses;
take-home supplies and similar costs; health and fitness club expenses an providers to members;
convenience products for injections; home or vehicular evaluations and modifications to meet the
environmental needs of the member or caregiver; fees charged by providers for services, supplies, or
equipment requested by member, but later refused by member. The purchase or rental of household
fixtures, including, but not limited to: exercise equipment; air purifiers; central or unit air conditioners,
water purifiers; humidifiers/dehumidifiers; hypoallergenic pillows; whirlpools and spas; mattresses or
waterbeds unless covered by Original Medicare.
• Prosthetic and corrective devices: Prosthetics that are primarily for patient convenience or are more
costly than equally effective alternative equipment. BCBSNC and Medicare coverage determinations
will be used.
• Religious, marital, family and sex counseling: Services and treatment related to religious counseling,
family counseling, marital/relationship counseling, sex therapy, adoption and pastoral counseling unless
covered by Original Medicare.
• Respite care: Medical care required to be arranged for, and provided to, a patient whose condition has
not changed (i.e., is stable) due only to the fact that the patient’s caregiver is absent.
• Sclerotherapy: Except when covered by Original Medicare as medically necessary and prior approved by
BCBSNC.
• Services the member is not legally obligated to pay, and services performed by a relative: Any service
for which the member legally would not be required to pay in the absence of this coverage; services
performed by a relative of member.
PAGE 13-16
Chapter 13
Claims billing and reimbursement
• Services furnished under a private contract: Services (other than for emergency or urgently needed
services) furnished by a physician as defined by the Social Security Act who has filed with the Medicare
carrier an affidavit promising to furnish Medicare covered services to Medicare beneficiaries only through
private contracts with the beneficiaries under section 1802(b) of the Social Security Act.
• Sex change or transformation: Any procedure or treatment designed to alter physical characteristics of
member from member’s biologically determined sex to those of another sex, regardless of any diagnosis
of gender role or psychosexual orientation.
• Treatment in a federal, state or governmental entity: To the extent allowed by applicable laws,
coverage for care and treatment provided in a hospital owned or operated by any federal, state or other
governmental entity, and care of military service-connected conditions for which the member is legally
entitled to services. This includes services provided to veterans in Veteran’s Affairs (VA) facilities. However,
reimbursement is allowed for the cost-sharing for emergency services receive at a VA hospital, up to the
appropriate cost sharing under the Plan.
• Vision: Vision care, except as provided by Original Medicare or as specified in the member’s certificate of
coverage. This exclusion/limitation includes, but it is not limited to: eye exercises; visual training;
orthoptics; and all types of contact lenses or corrective lenses unless specified in this certificate of coverage.
• Vehicular modifications: Unless covered by Medicare.
• Weight control: All services and supplies for the purpose of weight control; weight management and
commercial weight loss/reduction programs, unless covered by Original Medicare.
13.16
Using the correct NPI or BCBSNC assigned proprietary provider number for
reporting your health care services.
The National Provider Identifier (NPI) is a HIPAA mandate effective May 2007 for electronic transactions. The
NPI is a ten (10) digit unique health care provider identifier, which replaces the BCBSNC Proprietary Provider
Number (PPN) on electronic transactions. Additional information about NPI can be found at the Centers for
Medicare & Medicaid Services (CMS) Web site at https://nppes.cms.hhs.gov/NPPES/Welcome.do.
If your health care business submits claims using:
• Electronic transactions – filing with NPI is required
• Paper only (never electronically) – file with NPI or a BCBSNC assigned provider number
There are two (2) types of NPI that are assigned via the Centers for Medicare & Medicaid Services (CMS)
enumeration system, National Plan and Provider Enumeration System (NPPES):
• Type 1: Assigned to an individual who renders health care services, including physicians, nurses, physical
therapists and dentists. An individual provider can receive only one NPI.
• Type 2: Assigned to a health care organization and its subparts that may include hospitals, skilled nursing
facilities, home health agencies, pharmacies and suppliers of medical equipment (durable medical
equipment, orthotics, prosthetics, etc). An organization may apply and receive multiple NPIs to support
their business structure.
PAGE 13-17
Chapter 13
Claims billing and reimbursement
13.17
Using the correct Claim Form for reporting your health care services
BCBSNC recognizes and accepts the CMS-1500 (02-12) Claim Form or other similar forms for professional
providers and the UB-04 (CMS-1450) Claim Form for institutional/facility providers. The National Uniform
Billing Committee (NUBC) approved these forms that accommodate the reporting of the National Provider
Identifier (NPI), as the replacements of the forms predecessors CMS-1500 (02-12) and UB-04.
Most providers, billing agencies or computer vendors file claims to BCBSNC electronically using the HIPAA
compliant 837 formats. Providers who are not set up to file claims electronically should refer to the chart
below to determine the correct paper Claim Form to use:
Item
Explanation
Providers office
CMS-1500 (02-12) Claim Form or other similar forms
Home Durable Medical Equipment (HDME)
CMS-1500 (02-12) Claim Form or other similar forms
Reference lab
CMS-1500 (02-12) Claim Form or other similar forms
Licensed registered dietitian
CMS-1500 (02-12) Claim Form or other similar forms
Specialty pharmacy
CMS-1500 (02-12) Claim Form or other similar forms
Ambulance provider
CMS-1500 (02-12) Claim Form or other similar forms
Hospital facility
Form UB-04 (CMS-1450)
Ambulatory surgical center
Form UB-04 (CMS-1450) or CMS-1500 (02-12) Claim Form or
other similar forms
Skilled nursing facility
Form UB-04 (CMS-1450)
Lithotripsy provider
Form UB-04 (CMS-1450)
Dialysis provider
Form UB-04 (CMS-1450)
Home health care
• Home health provider
• Private duty nursing
• Home infusion provider
Form UB-04 (CMS-1450)
Form UB-04 (CMS-1450)
CMS-1500 (02-12) Claim Form or other similar forms
Please note that providers with electronic capability who submit paper claims will be asked to resubmit claims
electronically.
For more information on the CMS-1500 (version 02-12) Claim Form or other similar forms; or the UB-04 Claim
Form, visit the National Uniform Claim Committee (NUCC) Web site at www.nucc.org.
PAGE 13-18
Chapter 13
Claims billing and reimbursement
13.17.1 CMS-1500 (02-12) Claim Form or other similar forms claim filing instructions
Field #
Description
1
Leave blank
1a
Insured’s ID - Enter the member identification number exactly as it appears on the patient’s ID card.
The member’s ID number is the letter J followed by the subscriber number and the 2-digit suffix
listed next to the member’s name on the ID card. This field accepts alpha and numeric characters.
2
The patient’s name should be entered as last name, first name, and middle initial.
3
Enter the patient’s birth date and sex. The date of birth should be 8 positions in the
MM/DD/YYYY format. Use 1 character (X) to indicate the sex of the patient.
4
Enter the name of the insured. If the patient and insured are the same, then the word same
may be used. This name should correspond with the ID # in field 1a.
5
Enter the patient’s address and telephone number.
6
Use 1 character (X) to indicate the patient’s relationship to the insured.
7
Enter insured’s address and telephone number. If patient’s and insured’s address are the same
then the word “same” may be used.
8
Enter the patient’s marital and employment status by marking an (X) in 1 box on each line.
9
Show the last name, first name, and middle initial of the person having other coverage that
applies to this patient. If the same as Item 4, enter same (complete this block only when the
patient has other insurance coverage). Indicate none if no other insurance applies.
9a
Enter the policy and/or group number of the other insured’s policy.
9b
Enter the other insured’s date of birth (MM/DD/YYYY) and sex.
9c
Enter the other insured’s employer’s name or school name.
9d
Enter the other insured’s insurance company name.
10 a-c
Use 1 character (X) to mark yes or no to indicate whether employment, auto accident, or
other accident involvement applies to services in Item 24 (diagnosis).
11
Enter member’s policy or group number.
11a
Enter member’s date of birth (MM/DD/YYYY) and sex.
11b
Enter member’s employer’s name or school name.
11c
Enter member’s insurance plan name.
11d
Check yes or no to indicate if there is, or not, another health benefit plan. If yes, complete
items 9 through 9d.
12
Have the patient or authorized person sign or indicate signature on file in lieu of an actual
signature if you have the original signature of the patient or other authorized person on file
authorizing the release of any medical or other information necessary to process this claim.
Continued on the following page.
PAGE 13-19
Chapter 13
Claims billing and reimbursement
Field #
Description
13
Have the subscriber or authorized person sign or indicate signature on file in lieu of an actual
signature if you have the original signature of the member or other authorized person on file
authorizing assignment of payment to you.
14
Enter the date of injury or medical emergency. For conditions of pregnancy enter the LMP. If
other conditions of illness, enter the date of onset of first symptoms.
15
If patient has previously had the same or similar illness, give the date of the previous episode.
16
Leave blank.
17
Enter name of referring physician or provider.
17a
Enter ID number of referring physician or provider.
17b
Enter 1B (BCBSNC ID qualifier) in the shaded area and to the immediate right of 17a. Enter
the BCBSNC ID number of the referring provider in the shaded box to the right of the ID
qualifier. (This field is only required if the NPI number is not reported in Box 17B.
Example:
17a. 1B
12345
17b. NP1
1234567891
18
If services are provided in the hospital, give hospitalization dates related to the current services.
19
Leave blank.
20
Complete this block to indicate billing for clinical diagnosis tests.
21
Enter the diagnosis/condition of the patient indicated by the ICD-9 code. Enter only the
diagnosis code, not the narrative description. Enter up to 4 codes in priority order (primary,
secondary conditions). The primary diagnosis should be reported in diagnosis #1.
The secondary in #2. Contributing diagnosis in #3 and #4.
When entering the number, include a space (accommodated by the period) between the 2
sets of numbers. If entering a code with more than 3 beginning digits (e.g., E codes), enter
the fourth digit on top of the period.
Example:
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Retype Items 1,2, 3 or 4 to item 24E by Line)
1.
998 . 59
3.
V18 . 0
2.
780 . 6
4.
E87 . 88
22
Leave blank.
23
Enter certification of prior review number here if services require it.
24
The 6 service lines in section 24 have been divided horizontally to accommodate submission
of both the NPI number and BCBSNC identifier during the NPI transition, and to accommodate
the submission of supplemental information to support the billed service. The top area of the
6 service lines is shaded and is the location for reporting supplemental information. It is not
intended to allow the billing of 12 lines of service. Use of the supplemental information fields
should be limited to the reporting of NDC codes. If reporting NDC codes, report the NDC
qualifier “N4” in supplemental field 24a followed by the NDC code and unit information
(UN = unit; GR = gram; ML = milliliter; F2 = international unit).
Example:
24. A.
MM
DATE(S) OF SERVICE
From
To
DD
YY
MM
DD
YY
B.
C.
PLACE OF
SERVICE EMG
D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
N400026064871 Immune Globulin Intravenous
10 01 05 10 01 05 11
J1563
E.
DIAGNOSIS
POINTER
F.
$ CHARGES
G.
DAYS
OR
UNITS
H.
I.
EPSDT ID.
Family
Plan QUAL.
UN2
1B
13
500 00
20 N
NPI
J.
RENDERING
PROVIDER ID. #
12345678901
0123456789
Continued on the following page.
PAGE 13-20
Chapter 13
Claims billing and reimbursement
Field #
Description
24a
Enter the month, day, and year (6 digits) for each procedure, service and/or supply in the
unshaded date fields. Dates must be in the MM/DD/YY format.
24b
Enter the appropriate place of service codes in the unshaded area.
24c
Leave blank.
24d
Enter procedure, service, or supplies using the appropriate CPT or HCPCS code in the
unshaded area. Also enter, when appropriate, up to 4 two-digit modifiers.
24e
Enter the diagnosis reference number (pointer) in the unshaded area. The diagnosis pointer
references the line number from field 21 that relates to the reason the service(s) was performed
(ex. 1, 2, 3, or 4, or multiple numbers if the service relates to multiple diagnosis from field 21).
The field accommodates up to 4 digits with no commas between numbers.
24f
Enter the total charges for each line item in the unshaded area. Enter up to 6 numeric
positions to the left of the vertical line 2 positions to the right. Dollar signs are not required.
24g
Enter days/units in the unshaded area. This item is most commonly used for units of supplies,
anesthesia units, etc. Anesthesia units should be 1 unit equals a 1-minute increment. Do not
include base units of the procedure with the time units. If you are billing services for consecutive
dates (from and to dates) it is critical that you provide the units accurately in block 24g.
24h
Leave blank.
24i
Enter 1B (BCBSNC ID qualifier) in box 24i above the dotted line (not required if submitting
NPI number).
24j
Enter the assigned BCBSNC provider identification number for the performing provider in the
shaded area. If several members of the group shown in Item 33 have furnished services, this
item is to be used to distinguish each provider of service. (This field is only required if the NPI
number is not being reported.)
Enter the NPI number of the performing provider below the dotted line. If several members of
the group shown in Item 33 have furnished services, this item is to be used to distinguish each
provider of service.
J.
Example:
RENDERING
I.
ID.
QUAL.
1B
NPI
PROVIDER ID. #
01234
12345678901
25
Enter federal tax identification number.
X Indicate whether this number is Social Security Number (SSN) or Employer Identification
Number (EIN).
26
Enter the patient account number assigned by physician’s/provider’s/supplier’s accounting system.
27
Accept assignment
X Yes must be indicated in order to receive direct reimbursement. Contracting providers
have agreed to accept assignment.
28
Enter the total charges for all services listed on the Claim Form in item 24F. Up to 7 numeric
positions can be entered to the left of the vertical lines and 2 positions can be entered to the
right. Dollar signs are not required.
Continued on the following page.
PAGE 13-21
Chapter 13
Claims billing and reimbursement
Field #
Description
29
Enter the amount paid by the primary insurance carrier. (Reminder: Only copayments may be
collected at time of service.)
30
Enter total amount due - charges minus any payments received.
31
Signature and date of the physician/provider/supplier. (Stamped signatures are accepted.)
32
Enter the name and address of the facility site where services on the claim were rendered. This
field is especially helpful when this address is different from billing address in item 33.
32a
Enter the NPI number of the service facility.
32b
Enter the ID qualifier 1B immediately followed by the BCBSNC assigned 5-digit provider
identification number for the service facility (this field is not required if submitting the NPI
number in field 32a).
Example: CRABTREE MEDICAL CENTER
32. SERVICE FACILITY LOCATION INFORMATION
100 AIRPORT ROAD
RALEIGH, NC 27610
a.
12344567891
NPI
b.
1B01234
33
Enter the name, address, and phone number for the billing provider or group.
33a
Enter the NPI number of the billing provider or group.
33b
Enter the ID qualifier 1B immediately followed by the BCBSNC assigned 5-digit provider
identification number for the billing provider or group (this field is not required if submitting
the NPI number in field 33a).
(
)
Example: DR. JUDD KILGORE
33. BILLING PROVIDER INFO & PH #
P O BOX 1678
RALEIGH, NC 27610
a.
1987654321
NPI
b.
1B03456
PAGE 13-22
Chapter 13
Claims billing and reimbursement
13.17.2 Sample CMS-1500 (02-12) Claim Form
PAGE 13-23
Chapter 13
Claims billing and reimbursement
13.17.3 UB-04 claim filing instructions
Form
locator number
Description of content
1
•
Provider name
• Street address or post office box
• City, state, zip code
• (Area code) telephone number
2
Required when the address for payment is different than that of the billing provider
information located in form locator1
• Pay-to name
• Pay-to address
• Pay-to city, state, zip
3a
Provider assigned patient control number
3b
Provider assigned medical/health record number (if available)
4
Type of bill (4 digit classification)
• Digit 1: Leading zero
• Digit 2: Type of facility
+ 1 = Hospital
+ 2 = Skilled nursing facility
+ 3 = Home health
+ 7 = Clinic
+ 8 = Special facility
• Digit 3: Bill classification
+ 1 = Inpatient
+ 3 = Outpatient
+ 4 = Other
• Digit 4: Frequency
+ 1 = Admit through discharge claim
+ 2 = Interim - first claim
+ 3 = Interim - continuing claim
+ 4 = Interim - last claim
+ 5 = Late charge
** For further explanation on type of bill, please refer to the NUBC UB-04 official data
specifications manual.
5
Provider’s federal tax identification number
6
Date(s) of service (enter MMDDYY, example 010106)
7
Leave blank
8a
Patient ID (required if different than the subscriber/insured ID in form locator 60)
8b
Patient’s name (last name, first name, middle initial)
9a
Patient’s address – street
Continued on the following page.
PAGE 13-24
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
9b
Patient’s address – city
9c
Patient’s address – state
9d
Patient’s address zip
9e
Patient’s address – county code (if outside US) (Refer to USPS Domestic Mail Manual)
10
Patient’s date of birth (enter MMDDYYYY, example 01012006)
11
Patient’s sex (M/F/U)
12
Admission/start of care date (MMDDYY)
13
Admission hour
Code
00
01
02
03
04
05
06
07
08
09
10
11
14
Code
12
13
14
15
16
17
18
19
20
21
22
23
Time PM
12:00-12:59 noon
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
Type of admission/visit
1.
2.
3.
4.
5.
9.
15
Time AM
12:00-12:59 midnight
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
Emergency
Urgent
Elective
Newborn
Trauma
Information not available
Source of admission or visit
1.
2.
3.
4.
5.
6.
7.
8.
9.
Physician referral
Clinic referral
HMO referral
Transfer from a hospital
Transfer from a skilled nursing facility
Transfer from another health care facility
Emergency room
Court/law enforcement
Information not available
Continued on the following page.
PAGE 13-25
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
15 (continued)
Source of admission or visit (continued)
A. Transfer from a critical access hospital
B. Transfer from another home health agency
C. Readmission to same home health agency
D. Transfer from hospital inpatient in the same facility resulting in a separate
claim to the payer
For newborns
1.
2.
3.
4.
16
Normal delivery
Premature birth
Sick baby
Extramural birth
Discharge hour:
Code
00
01
02
03
04
05
06
07
08
09
10
11
17
Time AM
12:00-12:59 midnight
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
Code
12
13
14
15
16
17
18
19
20
21
22
23
Time PM
12:00-12:59 noon
01:00-01:59
02:00-02:59
03:00-03:59
04:00-04:59
05:00-05:59
06:00-06:59
07:00-07:59
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
Patient discharge status
01 – Discharged to home/self care (routine discharge)
02 – Discharged/transferred to hospital
03 – Discharged/transferred to skilled nursing facility
04 – Discharged/transferred to an intermediate care facility
05 – Discharged/transferred to another type of institution
06 – Discharged/transferred to home under care of Home Health
07 – Left against medical advice
20 – Expired
30 – Still patient
43 – Discharged/transferred to a federal health care facility
50 – Hospice - home
51 – Hospice - medical facility (certified) providing hospice level of care
61 – Discharged/transferred to a hospital based Medicare approved swing bed
62 – Discharged/transferred to an Inpatient Rehabilitation Facility (IRF) including
rehabilitation distinct part units of a hospital
63 – Discharged/transferred to a Medicare certified Long Term Care Hospital (LTCH)
Continued on the following page.
PAGE 13-26
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
17 (continued)
64 – Discharged/transferred to a nursing facility certified under Medicaid but not
certified under Medicare
65 – Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit
of a hospital
66 – Discharged/transferred to a Critical Access Hospital (CAH)
18-28
Condition codes
(as applicable)
09 – Neither patient nor spouse is employed
11 – Disabled beneficiary but no LGHP
71 – Full care in unit
C1 – Approved as billed
C5 – Post payment review applicable
C6 – Admission preauthorization
** For additional condition codes, please refer to the NUBC UB-04 official data
specifications manual
29
Accident state (situational)
+ Required when the services reported on this claim are related to an auto accident
and the accident occurred in a country or location that has a state, province, or
sub-country code.
30
Leave blank
31-34
Occurrence codes and dates
(as applicable)
01 – Accident/medical coverage
02 – No fault insurance involved
03 – Accident/tort liability
04 – Accident employment related
05 – Accident no medical/liability coverage
06 – Crime victim
Medical condition codes
09 – Start of infertility treatment cycle
10 – Last menstrual period (only applies for maternity related care)
11 – Onset of symptoms/illness
Insurance related codes
24 – Date insurance denied
25 – Date benefits terminated by primary payer
Covered by EGHP
A1 – Birthdate of primary subscriber
B1 – Birthdate of second subscriber
C1 – Birthdate of third subscriber
A2 – Effective date of the primary insurance policy
B2 – Effective date of the secondary insurance policy
C2 – Effective date of the third insurance policy
** For additional occurrence codes, please refer to the NUBC UB-04 official data
specifications manual
Continued on the following page.
PAGE 13-27
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
35-36
Occurrence span codes and dates
(as applicable)
70 – Qualifying stay dates for SNF use only
71 – Prior stay dates
72 – First/last visit dates
74 – Noncovered level of care/leave of absence dates
** For additional occurrence span codes, please refer to the NUBC UB-04 official data
specifications manual
37
Leave blank
38
Responsible party name and address
39-41
Value codes
01 – Most common semi-private rooms
02 – Provider has no semi-private rooms
08 – Lifetime reserve amount in the first calendar year
45 – Accident hour
50 – Physical therapy visit
A1 – Inpatient deductible Part A
A2 – Inpatient coinsurance Part A
A3 – Estimated responsibility Part A
B1 – Outpatient deductible
B2 – Outpatient coinsurance
**For additional value codes, please refer to the NUBC UB-04 official data
specifications manual
42
Revenue code (refer to UB-04 manual)
43
Revenue description (refer to UB-04 manual)
44
HCPCS/rates
• The HCPCS applicable to ancillary service and outpatient bills
• The accommodation rate for inpatient bills
45
Service date (MMDDYY)
• Applies to lines 1-22
Creation date (MMDDYY)
• Applies to line 23 – the date bill was created/printed
46
Unit of service
47
Total charges by revenue code category (0001=total charges should be reported on
line 23 with the exception of multiple pages which should be reported on line 23 of
the last page)
48
Noncovered charges
Continued on the following page.
PAGE 13-28
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
50 (A, B, C)
Insurance carrier name (payer)
• Line A - primary payer
• Line B - secondary payer
• Line C - tertiary payer
51
Health plan identification number (leave blank until mandated)
52 (A, B, C)
Release of information
• I = Informed consent to release medical information for conditions or diagnoses
(signature is not on file)
• Y = Provider has a signed statement permitting release of medical/billing date
related to a claim
53 (A, B, C)
Assignment of benefits
• N = No
• Y = Yes (must be indicated in order to receive direct reimbursement)
• Contracting providers have agreed to accept assignment
54 (A, B, C)
Prior payments/source
• A - Primary payer
• B - Secondary payer
• C - Tertiary payer
55 (A, B, C)
Estimated amount due (not required)
56
National Provider Identifier (NPI) – billing provider
57 (A, B, C)
Other billing provider ID (BCBSNC provider number on appropriate line) – required
if NPI is not reported on FL56
58 (A, B, C)
Subscriber’s/insured name (last name, first name)
59 (A, B, C)
Patient’s relationship to subscriber/insured
01 – Spouse
18 – Self
19 – Child
20 – Employee
21 – Unknown
39 – Organ donor
40 – Cadaver donor
53 – Life partner
G8 – Other relationship
60 (A, B, C)
Subscriber’s/insured identification number
61 (A, B, C)
Subscriber’s/insured group name
62 (A, B, C)
Subscriber’s/insured group number
63 (A, B, C)
Treatment authorization code
Continued on the following page.
PAGE 13-29
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
64 (A, B, C)
Document Control Number (DCN) [leave blank]
65 (A, B, C)
Subscriber’s/insured employer name
66
Diagnosis and procedure code qualifier (ICD version indicator) – this will be ICD-9
until ICD-10 is in effect
67
Principal diagnosis code “ICD-9” (do not enter decimal, it is implied)
• Eighth position indicates Present on Admission indicator (POA) – not required for
BCBSNC commercial business
+ Y = Yes
+ N = No
+ U = No information in the record
+ W = Clinically undetermined
67 (A-Q)
Other diagnosis codes “ICD-9”
• Eighth position indicates Present On Admission indicator (POA) – required for
inpatient claims
+Y = Yes
+N = No
+U = No information in the record
+W = Clinically undetermined
68
Leave blank
69
Admitting diagnosis (inpatient only)
70 (A, B, C)
Patient’s reason for visit (outpatient only)
71
Prospective Payment System code (PPS) [not required]
72 (A, B, C)
External cause of injury code “E-Code”
73
Leave blank
74
Principal procedure code and date
• ICD-9 code required on inpatient claims when a procedure was performed
(do not enter decimal, it is implied)
• Leave blank for outpatient claims
• Date format MMDDYY
74 (A-E)
Other procedures codes and dates (procedures performed during the billing period
other than those coded in FL74)
• ICD-9 code required on inpatient claims when a procedure was performed
(do not enter decimal, it is implied)
• Leave blank for outpatient claims
• Date format (MMDDYY)
75
Leave blank
Continued on the following page.
PAGE 13-30
Chapter 13
Claims billing and reimbursement
Form
locator number
Description of content
76
Attending physician (NPI, last name and first name)
• If NPI is not reported, report 1G in the secondary identifier qualifier field and
UPIN in the secondary identifier field
77
Operating physician (NPI, last name and first name)
• If NPI is not reported, report 1G in the secondary identifier qualifier field and
UPIN in the secondary identifier field
78-79
Other physician (NPI, last name and first name)
• If NPI is not reported, report 1G in the secondary identifier qualifier field and
UPIN in the secondary identifier field
80
Remarks
81 (A-D)
Code - code field (overflow field to report additional codes)
PAGE 13-31
Chapter 13
Claims billing and reimbursement
13.17.4 Sample UB-04 Claim Form
PAGE 13-32
Chapter 13
Claims billing and reimbursement
13.17.5 Policy on payment for remaining codes
Sample versions of completed Claim Forms are
available in The Blue BookSM Provider Manual,
located in Chapter 9, Claims billing and
reimbursement. These forms may be viewed on the
bcbsnc.com Web site for providers at bcbsnc.com/
providers/blue-book.cfm. When viewing the
sample Claim Forms contained in The Blue Book,SM
it’s important to remember that when submitting
claims for Blue Medicare HMOSM and Blue Medicare
PPOSM members, always use your assigned provider
and/or group number for Blue Medicare HMOSM
and/or Blue Medicare PPOSM transactions, if not
filing via NPI.
13.18
HCPCS codes
Reminder:
BCBSNC has been and will continue to allow the
submission of HCPCS codes. In fact, their use is
encouraged especially when filing for the
administration of medications.
When submitting claims with a medication code of
“J,” it is important to refer to the HCPCS code
book, paying particular attention to the dose that is
listed to ensure appropriate reimbursement exactly
as they appear in the HCPCS book.
Example 1:
A patient is given ten (10) mg of valium. The HCPCS
code for Valium, J3360, reads “injection, diazepam
up to five (5) mg.” The provider should enter two (2)
(# of units) in the “G” field (days and unit field) to
indicate that a total of ten (10) mg of Valium was
given. If the number of milligrams is entered instead
of the number of units, the claim will be incorrect.
Also, when filing code J3490, unclassified drugs, a
description or name of the medication and dose
given must be submitted on the Claim Form for
payment. The claim cannot be processed without
this vital piece of information and would more than
likely be denied for medical justification.
Example 2:
A forty-eight (48) year-old man with mild diabetes
on single drug therapy with an oral agent receives a
comprehensive examination. He had not had a
similar evaluation in three (3) years, being seen only
rarely for brief visits, as he was asymptomatic and
doing well on his previous examination. A CBC,
Chem Profile, Urinalysis and Glycosolated Hemoglobin
are obtained.
The patient is counseled regarding cigarette smoking;
with control and prudent low cholesterol diet is
advised and briefly described.
For this visit, the diagnosis code V70.0 should be
used. Code 250.0 for Diabetes Mellitus should be
listed next to the Glycosolated Hemoglobin as a
secondary diagnosis.
The appropriate procedure code would be 99396,
which is the preventive medicine CPT code for an
established patient forty to sixty-four (40-64).
Example 3:
A sixty-three (63) year-old female received a
comprehensive evaluation after not being seen in
the physician’s office for over one (1) year. Two (2)
years prior to this visit she had a successful resection
of colon carcinoma and four (4) years prior to the
visit she had an uncomplicated myocardial
infarction. The current visit was precipitated by the
development of shortness of breath, swelling of the
lower extremities and weight gain. The patient was
known to have mild diabetes, but was taking no
medication. Physical examination was normal except
for obesity and a trace of pretibial edema.
Since it had been several years since she had had an
internal examination and pap smear, that procedure
was performed. There were no symptoms or
findings related to that part of her examination.
Multiple laboratory tests, as well as an electrocardiogram
and chest x-ray were requested. The patient was
counseled regarding weight loss and a low sodium
diet. A return visit was scheduled.
PAGE 13-33
Chapter 13
Claims billing and reimbursement
For this visit, the procedure code 99215 should be
used. An appropriate diagnosis code should be
utilized as the primary diagnosis. The preventive
code V70.0 should also be listed as a secondary
diagnosis since certain preventive services are
rendered. Code V72.3 should be used beside the
pap smear to justify this as a routine procedure.
Field #
New
New
Less than 1 year
99381
99391
1 to 4
99382
99392
5 to 11
99383
99393
12 to 17
99384
99394
Example 4:
An eighteen (18) year-old high school student is
seen for a scheduled covered routine general health
evaluation. The student also requests completion of
a pre-employment form for a summer job. He plans
to enter college in the fall and anticipates needing
student health forms and immunization records at
that time. The patient is healthy and has no
complaints. He had been seen in the office before,
but not for several years. No problems are revealed
by a complete review of his history, and a complete
physical examination is normal. The required preemployment form is completed. No counseling of
significance is necessary. For this visit, the appropriate
diagnosis code would be V70.0.
18 to 39
99385
99395
40 to 64
99386
99396
65 years and over
99387
99397
Routine GYN exam
99203 or
99213 or
99204 or
99214 or
99384-99387 99394-99397
Preventive
counseling codes*
99401-99404 99401-99404
The procedure code should be preventive code
99385 or 99395, depending on whether the patient
had been seen prior to this visit, within the last three
(3) years.
Note: If a physical was scheduled for the preemployment physical alone, this would not be
covered, as this is an exclusion per the certificate of
coverage.
13.19
ICD-9 and CPT codes for well
exams
When filing claims for well exam, you must use the
correct ICD-9 and CPT codes. Please refer to the
chart or call customer services or your Network
Management representative if you need assistance.
Preventive medicine CPT codes 99381-99397 include
counseling.
* Codes used to report services provided at a
separate encounter. These codes are not
appropriate to use with CPT codes 99381-99397
or 99201-99215 or to use with ICD-9 codes V70.0,
V20.2 or V72.3.
Diagnosis codes:
• ICD-9 general medical examination code V70.0
(adults, age eighteen [18] and over) and V20.0
(children, newborn to seventeen [17] years of
age) should be used as the primary code for
services that are predominantly preventive.
• ICD-9 code V72.3 should be used as the
diagnosis code for the annual routine pelvic
examinations including pap smears.
Procedure codes:
• Preventive medicine codes 99385-99387 and
99395-99397 must be used when ICD-9 code
V70.0, adult preventive care, is the primary or
submitted diagnosis; 99381-99384 and 9939199394 must be used when ICD-9 code V20.0,
pediatric preventive care, is the submitted
diagnosis.
PAGE 13-34
Chapter 13
Claims billing and reimbursement
• CPT evaluation and management service codes
99201-99205 and 99211-99215 should be used
when services are predominantly for patient
complaints and/or illness and should be
selected according to criteria described in the
CPT manual.
Initial Preventive Physical Examination (IPPE) or
Welcome to Medicare Visit
• CPT Code G0402 is used to bill the IPPE visit.
The “Welcome to Medicare” visit is billed only
within the first twelve (12) months the member
has had Medicare.
Annual Wellness Visits (AWV)
• G0438 is used for the initial AWV and must
occur at least twelve (12) months after the
member’s “Welcome to Medicare” visit.
• G0439 is used for the subsequent AWV
Therefore, effective January 1, 2008 and dates after,
providers may no longer bill the “G” code to Part B,
instead the Part D plan should be billed for
reimbursement.
13.20.1 Safe handling of vaccines
Vaccines for immunizations can be temperature
sensitive and should be monitored for temperature
increases and decreases until they are administered.
Blue Medicare HMOSM and Blue Medicare PPOSM
members are not to pick-up vaccines from the
pharmacy for transport to a provider’s office, as this
may result in unsafe temperature changes. Vaccines
may only be obtained by the administering provider
and never by a Blue Medicare HMOSM or Blue
Medicare PPOSM member. Providers with questions
are encouraged to contact their Network
Management representative.
• AWVs are allowed once, every twelve (12) years
13.20.2 Medicare Part D vaccine manager for
13.20
Immunizations (Part D covered
vaccines)
Physicians and other providers who bill Medicare
carriers or Medicare administrative contractors (A/B
MACs) for the administration of Part D covered
vaccines to Medicare cannot bill Medicare Part B
(i.e., BCBSNC medical claims) for the administration
of Medicare Part D covered vaccines. Providers
billing staff should be aware of Part D covered
vaccine administration guidance for 2008. Section
202(b) of the Tax Relief and Health Care Act of 2006
(TRHCA) established a permanent policy for
payment by Medicare for administration of Part Dcovered vaccines, beginning in 2008. Specifically,
the policy states that effective January 1, 2008, the
administration of a Part D-covered vaccine is
included in the definition of “covered Part D drug”
under the Part D statute. During 2007, in transition
to the policy, providers were permitted to bill Part B
for the administration of a Part D vaccine using a
special G code (G0377). However, special edition
(SE) 0723 reminds providers of the requirement that
payment for the administration of Part D covered
vaccines was only during 2007.
claims filing
Participating providers have an easy online option to
submit Medicare Part D vaccine claims through
eDispense.TM eDispenseTM Part D vaccine manager, a
product of Dispensing Solutions, Inc. (DSI), is a
Web-based application, that offers a solution for the
submission and adjudication of claims for physician
administered Part D vaccine covered by member’s
Medicare Part D pharmacy benefits (vaccination
claims that cannot be submitted on a standard
CMS-1500 medical Claim Form or other similar
forms).
eDispenseTM makes real-time claims processing for
in-office administered Medicare Part D vaccines
available through its secure online access. Services
offered with eDispenseTM allow providers to quickly
and electronically verify member’s Medicare Part D
vaccination coverage and submit claims to our
pharmacy benefits manager directly from your
in-office internet connection.
eDispenseTM offers providers the ability to:
• Verify members’ Medicare Part D vaccination
eligibility and benefits in real time
PAGE 13-35
Chapter 13
Claims billing and reimbursement
• Advise members of their appropriate out-ofpocket expense for Medicare Part D vaccines
• Submit Medicare Part D vaccine claims
electronically to our Pharmacy Benefits Manager
(PBM)
Enrollment is an easy two (2) step process:
• Step 1 – select an authorized staff member who
is most likely to be the primary user of the
system to enroll the practice. This person should
be prepared to provide the following information
about the practice:
‡ Tax identification number
‡ National Provider Identifier (NPI)
‡ Medicare ID number
‡ Drug Enforcement Administration (DEA)
number
‡ State medical license number
• Step 2 – go to Dispensing Solutions’ Web site
and complete a simple onetime online
enrollment application at enroll.edispense.com.
Providers can contact Dispensing Solutions directly
for assistance with enrollment and claims by calling
their Customer Support Center at 1-866-522-EDVM
(3386).
Provider enrollment in eDispenseTM vaccine manager
and eDispenseTM facilitated transactions between the
PBM and providers is a voluntary option for
providers. Medicare Part D vaccine claims eligible
for electronic processing with eDispenseTM Part D
vaccine manager are reimbursed according to the
PBM allowance, less member liability. BCBSNC
offers network providers access to eDispenseTM
vaccine manager for Medicare Part D transactions
through our PBM.
13.21
Allergy testing
All allergy testing for members must be provided by
participating allergists who are board certified by
the American Board of Allergy and Immunology, or
participating board certified ENT allergists who have
completed requirements for fellowship in the
American Academy of Otolaryngic Allergy and have
been approved by the BCBSNC credentials committee.
The following are the exceptions:
• Allergy patch testing has been approved to be
performed by our participating dermatologists.
CPT code is 95044.
• Ophthalmic mucous membrane testing has
been approved to be performed by our
ophthalmologists. CPT code is 95060.
• Inhalation bronchial challenge testing has been
approved to be performed by our participating
pulmonary specialists. CPT code is 95070-95071.
Subsequent allergy injections may be provided by
other participating physicians such as the primary
care physician or other participating specialists when
referred by the primary care physician.
CPT codes used for allergy testing are 95004-95075
CPT codes used for allergy immunotherapy are
95115-95180.
Skin tests for specific drug immediate reactions
would be appropriate for any participating physician
specialty.
13.22
Criteria for approving additional
providers for allergy testing
• To certify that allergy testing throughout the
BCBSNC network of otolaryngic providers is
performed in a consistent manner, and by
physicians who have been adequately trained in
evaluation of allergic manifestations, the need
has arisen for standardization of criteria for
credentialing of privileges by otolaryngologists.
• Blue Cross and Blue Shield of North Carolina
(BCBSNC) will recognize and approve allergy
testing to otolaryngologists who are participating
providers in the BCBSNC network and who have
fulfilled the requirements and received
certification by the American Academy of
Otolaryngic Allergy (AAOA). Verification of
certification by the American Academy of
Otolaryngic Allergy should be provided by the
otolaryngologist upon application for privileges
for otolaryngic allergy testing.
PAGE 13-36
Chapter 13
Claims billing and reimbursement
• Background: Allergy testing for BCBSNC
members can be an important part of
determining causes of significant illnesses, as
well as being the basis for selecting a treatment
regimen for members who exhibit allergic
manifestations. After review of available
information, it appears appropriate and
reasonable to expect otolaryngic providers to
have gone through the requirements of the
American Academy of Otolaryngic Allergy and
to receive certification as ENT allergists in order
to be certified as a participating provider of
otolaryngic allergy testing.
• Exceptions may be made, on an individual
basis, by BCBSNC credentialing committee,
based on evidence of sufficient training and
experience in the field of ENT allergy.
13.23
Use of office or other outpatient
service code 99211
CPT code 99211 is described as “office or other
outpatient visit for evaluation and management of
an established patient, that may not require the
presence of a physician.” Usually the presenting
problems are minimal. Typically five (5) minutes are
spent performing or supervising these services.
The CPT code should not be used for an additional
charge when only laboratory, immunizations or other
diagnostics are performed.
For BCBSNC patients, this service code requires a
copayment to be charged and patients should not
have to pay a copayment if they are only reporting
for laboratory tests or x-rays.
For the service described by CPT code 99211 to
be billed:
• There should be a documented service by the
physician or physician office staff that is
separate from other procedures that are being
performed at the same time, such as injections
and diagnostic tests.
• The service should be clearly identifiable.
• A record of the service performed should be
entered into the patient’s medical record.
Examples:
• Office visit for a sixty-seven (67) year-old
established patient to re-dress an abrasion.
• Office visit of a seventy-two (72) year old
established patient, for a blood pressure check
and review medication.
13.24
Dispensing DME from the office
Prior authorization will not be required for covered
Durable Medical Equipment (DME) or medical
supply items if the item is:
• $600 or less by contracted rate and
• Filed with a valid HCPCS code and
• Filed by a participating provider/vendor
Prior authorization is required for all Durable Medical
Equipment (DME) less than $600 for payment by
BCBSNC. Unlisted, miscellaneous or customized
items will not have a contracted price as they are
priced based on individual consideration; therefore
these items generally will require prior authorization.
This allows us to make a determination of coverage
and inform you of the member’s copayment. To
pre-authorize the item, call medical services at
1-800-942-5695 or 1-336-760-4822 with the
following information:
• Name of item required and the HCPCS code
• Diagnosis
• What the device will be used for
• Clarification that the device is medically necessary
The following are some examples of noncovered
items or services:
• Theraputty
• Lumbar pillows or rolls
• Cervical pillows or rolls
• Educational supplies, such as books or manuals
• Theraband
You may bill the member if services are denied as
noncovered, (for example, EX 02). These services are
excluded in the member’s certificate of coverage.
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You may not balance bill the member if services
denied exceeds HMO guidelines (for example,
EX 56) or are considered included in a global
service, EX 36.
You should not have any problem receiving
reimbursement for the HCPCS “L” codes submitted
if you prior authorize the DME. Be aware that all
authorized HCPCS “L” code devices are considered
durable medical equipment and the applicable DME
copayment/coinsurance will be deducted by
BCBSNC at the time of claims submission.
13.25
Assistant surgery
Following are Blue Medicare HMOSM and Blue
Medicare PPOSM criteria for reimbursement for
assistant surgery procedures:
• The practitioner assisting surgery must be
credentialed by and participating with Blue
Medicare HMOSM and Blue Medicare PPO,SM but
does not have to be the same specialty or have
training equal to the primary surgeon. The
assistant surgeon is expected to comply with all
applicable statutes and regulations as appropriate
for assistant surgery.
• Physician reimbursement is limited to 16% of
the Blue Medicare allowable for the CPT code
submitted by the primary surgeon or charges,
whichever is less. Multiple surgery guidelines
apply to assistant surgeons when they are
assisting on multiple procedures. Physician
reimbursement for the second procedure is
limited to 8% of the Blue Medicare allowable or
charge, whichever is less. Reimbursement for
mid-level practitioners providing assistant
surgery is limited to 85% of the assistant surgeon
physician allowable for primary and multiple
procedures.
• The Plan utilizes assistant surgeon indicators
identified by industry standard coding software
to determine if the procedure indicates the use
of an assistant surgeon. When assistant at
surgery services are eligible for reimbursement,
providers are to bill using industry standard
modifiers.
13.26
Ancillary billing and claims
submission
For Blue Medicare HMOSM and Blue Medicare PPOSM
members, authorization of certain outpatient
services such as home health, durable medical
equipment, rehabilitation and requests for
nonparticipating providers may be required prior to
the initiation of services. Please verify member
benefits and review BCBSNC prior authorization
requirements detailed in Chapter 9, Prior
authorization requirements, of this manual, prior to
providing services.
DME providers should file claims for rental services
monthly, after thirty (30) consecutive days of rental,
or at the time the rental is determined to no longer
be medically necessary (whichever is first).
13.27
Ancillary billing
13.27.1 Participating reference lab billing
Definition – Reference clinical laboratory testing
services as may be requested by BCBSNC
participating providers. This would include, but not
be limited to, consulting services provided by
provider, courier service, specimen collection and
preparation at designated provider locations, and all
supplies necessary solely to collect, transport,
process or store specimens to be submitted to
provider for testing.
Billing
• Bill on CMS-1500 Claim Form or other similar
forms using CPT/HCPCS coding
• Specify services provided and include all of the
statistical and descriptive medical, diagnostic
and patient data
• Use appropriate provider number
• File claims after complete services have been
provided
• Laboratory procedure reimbursement includes
the collection, handling and conveyance of the
specimen
• All services provided should be billed as global
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13.27.2 Dialysis services billing
Definition – For services involved in the process of
removing blood from a patient whose kidney
functioning quality is faulty, purifying that blood by
dialysis, and returning it to the patient’s bloodstream.
Billing – Provider agrees to:
• Billing on the UB-04 Claim Form using only those
revenue codes indicated as billable dialysis
facility services, along with the corresponding
CPT codes and HCPCS codes.
• Not bill for routine laboratory, pharmaceutical,
and supplies that Medicare considers to be
included under the composite dialysis rate
(dialysis inclusive rate).
• Bill for non-routine (separately billable)
laboratory, and pharmaceuticals that Medicare
considers to be not included under the
composite dialysis rate.
The in-home hemodialysis inclusive rate per
treatment is the same as the in-center hemodialysis
inclusive rate per treatment.
13.27.3 Skilled Nursing Facility (SNF) billing
Definition – Skilled nursing care is care and/or
skilled rehabilitation services, which must be
furnished by or under the supervision of registered
or licensed personnel and under the direction of a
physician to assure the safety of the member and
achieve the medically desired result. Skilled
rehabilitation therapy includes services provided by
physical therapists, occupational therapists, and
speech pathologists or audiologists. The member
must require continuous (daily) skilled nursing
services for the level of care to be considered covered.
Billing
• Bill on UB-04 Claim Form.
• The patient must require continuous (daily)
skilled nursing services for the level of care to
be considered covered.
• The medical record will contain documentation
substantiating coding classification, such as in
the form of a completed MDS (minimum data
set) scoring tool.
• The following exclusionary services require prior
approval from BCBSNC health service
department: specialty beds, DME for personal
and/or home use, customized prosthetics and
orthotics, ambulance transport, diagnostic
procedures and lab work not routinely carried
out by the facility.
13.27.4 Ambulatory Surgical Center (ASC)
billing
Definition – Surgical procedures grouped by
complexity (as defined by Medicare).
Billing
• Outpatient surgery, radiology, laboratory, and
other diagnostic services must be billed by CPT
code.
• Providers should always submit the appropriate
CPT code to indicate the primary procedure.
• All ancillary services and supplies provided in
conjunction with an ambulatory surgical
procedure, including those delivered within
seventy-two (72) hours prior to the surgical
procedure, must be billed on the same UB-04
form.
Incidental procedure – An incidental procedure is
one that is carried out at the same time as a more
complex primary procedure and requires little
additional resources and/or is clinically integral to
the performance of the primary procedure. For
these reasons, an incidental procedure should not
be reimbursed separately on a claim. Procedures
that are considered incidental when billed with
related primary procedures on the same date
of service will be denied. Incidental procedures are
identified by medical review and are considered a
contractual adjustment.
Integral procedure – Procedures considered integral
occur in multiple surgery situations when one (1) or
more of the procedures are considered an integral
part of the major or principle procedure. Integral
procedures are considered to be those commonly
carried out as part of a total service and will not be
reimbursed separately.
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13.27.5 Home Durable Medical Equipment (DME) and billing
Definition – Durable medical equipment services are defined by CPT codes, and by HCPCS codes as set forth
in the AMA HCPCS Level I and Level II guidelines.
Billing – Bill on a typed electronic CMS-1500 Claim Form or other similar forms.
Payment – rentals
• All rentals and all rentals converted to purchase require prior authorization.
• Always include rental modifier code on rental Claim Forms.
• Bill each month of rental as one (1) unit.
Payment – repairs/maintenance
• Non-routine repairs that require the skill of a technician may be eligible for reimbursement.
• The labor component of the repair should be billed under the appropriate repair code.
• All replacement parts should be billed separately under the appropriate HCPCS code(s).
• Repairs may only be billed on purchased items and require prior authorization.
• Repairs may not be billed on rented equipment.
• All claims with a repair code should be submitted with a complete description of the services provided.
• When submitting a claim with a repair or maintenance modifier code and other modifier codes, list the
repair or maintenance modifier code first after the procedure code.
• Losses resulting from abuse/misuse of equipment or items are excluded from coverage.
• Maintenance services require prior authorization.
Certain drugs and supplies
With the January 1, 2006, implementation of Medicare Part D, which is Medicare prescription drug coverage,
certain drugs and supplies are covered only under the BCBSNC member’s prescription drug benefits.
This means that providers need to know whether or not they are in-network for the prescription drug benefits,
as well as be able to distinguish between Medicare Part B and Part D coverage in order to know how to bill
properly for a given drug or supply.
In order to be in-network for the Medicare Part D prescription drug benefits, durable medical equipment
providers must be in the Prime Therapeutics, LLC (Prime) network. Prime is BCBSNC’s Part D pharmacy
benefits manager. Durable medical equipment providers who contract only with BCBSNC, but not with Prime,
are in-network only for Part B benefits and are out-of-network for Part D benefits. Durable medical equipment
providers that are also pharmacies that would like to participate with Prime may contact Prime directly at
1-877-823-6373 or by email to: PharmacyOps@PrimeTheraPeutics.com.
When billing for the drugs and supplies that are covered under Medicare Part B, providers need to follow all
Medicare Part B coverage guidelines. Providers must follow the Medicare Part D coverage guidance when
billing for drugs and supplies that are covered under Medicare Part D.
Modifiers RP applicable to purchased items only
• Modifier RP must be filed when submitting claims for maintenance and repairs
Miscellaneous
• For manual and motorized wheelchairs and scooters, the Plan has the right to authorize these items as
rental items if Medicare has rental rates.
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Use of E1399 and other miscellaneous codes
Do not use E1399 or other miscellaneous HCPCS codes for items which have a designated HCPCS code.
• Special documentation is required for claims using miscellaneous codes, including E1399.
Always submit:
1. With each claim a complete description of the item.
2. With each initial claim a factory invoice for the item (catalogs and retail price listings are not acceptable).
• Failure to provide appropriate documentation when using E1399 and other miscellaneous codes can result
in processing delays and/or denials.
Please note:
• Do not staple these or any other enclosures to the Claim Form.
• Submit all initial claims on paper to ensure the appropriate documentation is received in the same envelope.
• Electronically submitted claims will not transmit additional documents.
13.27.6 Home Health (HH) billing
Definition – Home health services are defined as follows:
Visits to the home to provide skilled services, including:
Home health services
Must be rendered by
Skilled Nursing (SN)
Registered nurse or licensed practical nurse
Physical Therapy (PT)
Licensed physical therapist or licensed physical therapist assistant
Occupational Therapy (OT)
Licensed occupational therapist
Speech Therapy (ST)
Licensed speech pathologist
Medical Social Service (MSW)
Medical social service (MSW)
Medical Social Service (MSW
Home health aide
Billing
Provider agrees:
• To bill on UB-04 Claim Form. Appropriate HCPCS codes are required in Box 44 of the UB-04 in order to
receive payment.
• To bill your retail charges.
• To use your appropriate provider number.
• To file claims after complete services have been provided.
• In addition to the home health visit, bill only the non-routine medical supplies listed in the agreement.
These are the only covered supplies that may be billed under the revenue codes listed (all other covered
supplies are considered routine).
• BCBSNC will not pay overtime/holiday rates.
• For non-routine supplies, include a valid HCPCS code with the revenue code on the UB-04.
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Revenue codes and service units
Service
Revenue code
Payment
Home health aide
571
visit
Medical social worker
561
visit
Occupational therapy
431
visit
Physical therapy
421
visit
Skilled nursing LPN
550
visit
Skilled nursing RN
551
visit
Speech therapy
441
visit
Home health services not billable as separate services (integral part of home health visit):
• Routine medical supplies provided in conjunction with home health services including those left at the
member’s home are considered an integral part of the home health visit reimbursement and cannot be
billed separately (under Home Durable Medical Equipment (HDME) provider number or any other
provider number).
• Assessment visits unless a skilled service is also rendered during the same visit.
• Supervisory visits unless a skilled service is also rendered during the same visit.
• Skilled nursing visits may not be billed on the same days as private duty nursing visits.
Billable non-routine home health supplies
Routine medical supplies provided in conjunction with home health services including those left at the
member’s home are considered an integral part of the home health visit reimbursement and cannot be billed
separately (under HDME provider number or any other provider number).
13.27.7 Home Infusion Therapy (HIT) billing
Definition – Home infusion therapy is defined as follows:
• The administration of prescription drugs and solutions in the home via one (1) of these routes:
‡ intravenous
‡ intraspinal
‡ epidural
‡ subcutaneous
Notice: Other medications eligible for reimbursement under the Home Infusion Therapy (HIT) schedule must
be injections administered during the same visit as the infusion therapy and require administration by a health
care provider such as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
Benefits for home infusion services are limited. The following is applicable only to services that have been
authorized by BCBSNC.
Billing
• Home infusion therapy requiring regular nursing services must be billed in three (3) components by the
home infusion therapy provider:
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Claims billing and reimbursement
1. Per diem component (covering all home
infusion services, equipment and supplies
except the prescription drug and licensing
nursing services) for each day the drug
is infused.
2. Nursing services provided by a Registered
Nurse (RN) or Licensed Practical Nurse (LPN),
and
3. Drug component (only bill for the quantity of
drug actually administered, not unused
mixed, compounded or opened quantities)
• Bill on the CMS-1500 Claim Form or other
similar forms
• Use your appropriate provider number
• File claims after services have been provided
• File claims within one hundred and eighty (180)
days of providing service
• Miscellaneous codes are valid for use only if no
suitable billing code is available. All claims using
miscellaneous codes must be submitted with a
complete description of the services rendered,
including the NDC numbers for the drugs
administered. Failing to provide appropriate
documentation when using miscellaneous codes
can result in delays and/or denials.
Bundled services
The following are included in the home infusion
therapy rates established in your contract and
reimbursement schedule and may not be billed
separately unless defined:
13.28
Hospital policies
The following are excerpts from the hospital
agreement that outlines the provider’s responsibility
as a participating facility. These policies are provided
in addition to the remainder of the policies in this
manual. Please review all sections of this manual
that pertain to you.
Access to medical records
The hospital agrees, as stated in the hospital
agreement, that BCBSNC shall have the right, upon
request and during normal business hours, to
inspect and copy records maintained by the hospital
pertaining to claims for hospital services.
Concurrent review
The hospital will participate in and cooperate with
BCBSNC in its utilization management and quality
improvement programs. Summaries of these
programs follow.
Credentialing
The hospital will participate in and cooperate with
BCBSNC credentialing and recredentialing
processes, and will comply with determinations
made pursuant to the same. Please also see
Chapter 19, Credentialing.
The hospital will complete requests for verifications
of privilege status regarding individual providers.
These verifications will include information regarding
a provider’s:
• Status and standing with hospital
• All training and nursing visits and all nursing
services
• Specialty classification
• Initial assessment and patient set-up
• Description of past actions
• Providers may not request members obtain
supplies or treatment from an office; to get
supplies/ treatment, home infusion must be
done in the home.
• Description of limitations
• Level of privileges
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13.29
Utilization management program
BCBSNC has developed and implemented a UM
program with the objective of assuring that medical
services delivered to BCBSNC members are timely,
appropriate and cost-effective.
Utilization management applies to all covered
members. For inpatient services, utilization
management activities include pre-admission and
admission review, continued stay or concurrent
review and discharge planning.
Pre-admission review is designed for monitoring and
evaluating the medical necessity, appropriateness
and required level of care for an elective admission
prior to its occurrence. The patient’s primary care
physician or the consulting specialist typically
initiates this process by obtaining authorization
through BCBSNC Care Management & Operations
department.
Admission review and concurrent review are
performed by BCBSNC registered nurses either
telephonically or through on-site visits to the facility.
Both processes, whether performed on-site or
telephonically, are coordinated through the hospital’s
utilization review department.
Admission review involves the determination of the
type of admission, either emergency or urgent, and
documentation that acute care is the appropriate
level of care for the patient’s illness or condition.
Concurrent review is a review of the member’s
medical record by BCBSNC registered nurses during
hospitalization to assess the continued medical
necessity and appropriateness of care. This
information is also used to begin the discharge
planning process.
BCBSNC primary objective of discharge planning is
to help patients, their families, health care
professionals and the community to ensure that the
gains achieved from hospital care are maintained or
enhanced for the continued health and welfare of
the patients following discharge. The discharge plan
is a process where patients’ needs are identified,
evaluated and assistance given in preparing them to
move from one level of care to another.
During the discharge planning process, BCBSNC
nurses assist in arranging and authorizing the
services needed upon discharge. They work with the
attending physicians, hospital discharge planners or
social workers, the patients and their families and
BCBSNC participating home health vendors to
coordinate the services that are covered by BCBSNC.
The nurses follow the ongoing treatment, status and
needs of the patient until services are no longer
needed or covered.
Retrospective review or claims review may also be
conducted as part of the utilization management
process. This process reviews the necessity and
appropriateness of medical services by compilation
and analysis of data after medical care is rendered
to determine practitioner and consumer patterns
of care.
If a hospital cannot provide adequate services to a
BCBSNC member seeking provider services from a
hospital, the hospital shall cooperate with the
BCBSNC member and the participating physician
who ordered the BCBSNC member’s admission or
treatment in obtaining appropriate care for the
BCBSNC member. Referrals shall be made to a
participating provider if required services are
available from such a facility.
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13.30
UB-04 claims filing and billing
coverage policies and procedures
for BCBSNC
13.30.1 Anesthesia
• May be charged individually as used or included
in a charge, based on time.
• A charge that is based on time must be
computed from the induction of anesthesia until
surgery is complete. This charge includes the
use of equipment (e.g., monitors), all supplies
and all gases.
• Anesthesia stand-by services are not covered
unless they are actually used. Bill anesthesia
services using revenue code R370.
13.30.2 Certified Registered Nurse
Anesthetist (CRNA)
• Must be filed on a CMS-1500 Claim Form or
other similar forms
• Minutes of time must be included
• Anesthesia codes must be submitted
13.30.3 Autologous blood
• Charges for autologous donations are covered
when such services are rendered for a specific
purpose (e.g., surgery is scheduled or the need
for using autologous blood is documented) and
then only if the patient actually receives the blood.
• Prophylactic autologous donations and longterm storage (e.g., freezing components) for an
indeterminate time period in case of future
need are not considered eligible for benefits.
• Blood used must be billed on the same claim as
the related surgery charges.
13.30.4 Autopsy and morgue fee
13.30.5 Critical care units
The following conditions must be met to be
considered a critical care unit:
• The unit must be in a hospital and physically
separate from general patient care areas and
ancillary service areas.
• There must be specific written policies that
include criteria for admission to and discharge
from the unit.
• Registered nursing care must be furnished on a
twenty-four (24) hour basis. A nurse-patient ratio
of one (1) nurse to two (2) patients per patient
day must be maintained.
• A critical care unit is not a post-operative
recovery room or a post-anesthesia room.
The charge for critical care unit (i.e., coronary care or
intensive care unit) has two (2) components:
• The room charge includes all items listed under
acute care.
• The nursing increment/equipment charge
includes the use of special equipment
(e.g., dinemapp, swan ganz, pressure monitor,
pressure transducer monitor, oximetry monitor,
etc.) cardiac defibrillators, oxygen, supplies
(e.g., electrodes, guidewires, telemetry
pouches) and additional nursing personnel.
To ensure appropriate benefit payments, the critical
care room charge should equal the corresponding
routine room rate (i.e., either the routine semiprivate or private rate). An accurate breakdown of
these components ensures correct claims processing.
Any claims received without a breakdown of these
components may be returned for correction.
13.30.6 Diabetes education (inpatient)
• Admissions solely for the purpose of diabetic
education are not covered under BCBSNC
certificates
• Autopsy and morgue fees are not covered
under BCBSNC certificates.
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13.30.7 Dietary nutrition services
• Medically necessary nutritional counseling may
be a covered benefit
13.30.12 Leave of absence days
• Other nutritional assessment services (e.g.,
Optifast) are not covered under BCBSNC
certificates
• BCBSNC does not provide coverage for
therapeutic leave of absence days occurring
during an inpatient admission whether in
connection with the convenience of the patient
or the treatment of the patient.
• If covered nutritional counseling is included on
the UB-04 Claim Form use revenue code R942
• This charge should be billed directly to the
patient as it is the patient’s liability.
13.30.8 EKG
• The charge for EKG services includes the use of
a room, qualified technicians and supplies (e.g.,
electrodes, gel)
13.30.9 Hearing aid evaluation
• Hearing aid evaluation, hearing aid fitting and
hearing screening are not covered under
BCBSNC certificates
13.30.10 Lab/blood bank services
• If billed on the UB-04 Claim Form use revenue
code R180 with zero charge in form locator 47.
13.30.13 Observation services
Observation beds are covered outpatient services
when it is determined that the patient should be
held for observation, but not admitted to inpatient
status. Use the following guidelines when billing
observation charges:
• Bill observation services under revenue code
R762.
• The charges related to an observation bed may
not exceed the most prevalent semi-private
daily room rate.
• The charge for clinical laboratory must include
the cost of all supplies related to the tests
performed and a fee for the administration of
the department.
• BCBSNC should not be billed for both an
observation charge and a daily room charge for
the same day of service.
• Arterial puncture charge should be included in
the charge for the test.
• Observation charges must include all services
and supplies included in the daily room charge.
13.30.11 Labor and delivery rooms
The labor room charge and delivery room charge
must include the cost of:
• The use of the room
• The services of qualified technical personnel
• Linens, instruments, equipment and routine
supplies
The hospital should not bill BCBSNC for an obstetrics
room in addition to the labor room when patient is
still in the labor room at the time of patient census.
• The daily room rate should not be billed for an
observation patient sent home before the
midnight census hour.
• When a patient receives services in, and is
admitted directly from an observation holding
area, such services are considered part of
inpatient care.
• Fees for use of emergency room or observation
holding area and other ancillary services
provided are covered as a part of inpatient
ancillaries.
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13.30.14 Operating room
• The operating room charge may be based on
time or per procedural basis. When time is the
basis for the charge, it must be calculated from
the induction of anesthesia to the completion of
the procedure.
• Operating room services should be billed using
revenue code R360.
13.30.15 Outpatient surgery
• All ancillaries and supplies associated with an
outpatient surgical procedure should be billed
on one (1) claim. This includes use of facility
(pre-operative area, operating room, recovery
room), all surgical equipment, anesthesia,
surgical supplies, drugs and nourishment.
• All charges associated with preoperative testing
performed within seventy-two (72) hours of the
surgical procedure should also be billed on the
same claim with the ancillaries and supplies for
outpatient surgery.
13.30.16 Personal supplies
• Personal supplies include items not ordered by
the physician or not medically necessary.
• These items are not covered by BCBSNC health
insurance. These items should be billed using
UB-04 revenue code R999.
• Example of personal supplies include:
‡ Hair brush
‡ Mouthwash
‡ Nail clippers
‡ Powder
‡ Razor
‡ Shampoo and conditioner
‡ Shaving cream
‡ Shoe horn
‡ Toothpaste
‡ Toothbrush
13.30.17 Pharmacy
Please also refer to Chapter 14.1, The BCBSNC
formulary in Chapter 14, Pharmacy and specialty
networks.
• All pharmacy charges should be billed to
BCBSNC using revenue code R250-R259.
13.30.18 Recovery room
• The charge for recovery room includes the costs
of nursing personnel, routine equipment (e.g.,
oxygen) and supplies, monitoring equipment
(e.g., blood pressure, cardiac, and pulse
oximeter), defibrillator, etc.
• Warming systems (e.g., Bair Hugger Patient
Warming System, hypo/hyperthermic unit,
radiant warmer, etc.) should not be billed to
BCBSNC or the patient.
13.30.19 Emergency room services
• Charges for ER visits and services resulting in an
admission, must be billed on the UB-04 for the
inpatient admission. These charges should not
be split out and billed separately.
• Charges for ER visits that do not result in an
approved admission, must be submitted
separately for consideration of payment. These
services will be subject to existing Prudent
Layperson Language and if approved will
reimburse according to the current outpatient
reimbursement for your facility.
13.30.20 POA indicators required
The Centers for Medicare & Medicaid Services (CMS)
requires completion of the Present on Admission
(POA) indicator for every diagnosis on an inpatient
acute care hospital claim.
Hospitals providing care for Blue Medicare HMOSM
and Blue Medicare PPOSM members are required to
follow CMS’ POA reporting guidelines when
submitting claims for services provided to our
members.
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For inpatient acute care Prospective Payment
System (PPS) discharges on or after October 1,
2008, certain diagnosis codes on claims could
trigger a higher paying DRG (Diagnosis Related
Groups) at the time of discharge (but not at the time
of admission). The DRG that must be assigned to
the claim will be the one that does not result in the
higher payment.
Effective for discharges on or after October 1, 2008,
Blue Medicare PPOSM and Medicare supplemental
products should apply CMS POA adjudication logic.
Providers will not be compensated for those services
that are nonreimbursable as identified in CMS’
hospital-acquired conditions and present on
admission indicator reporting program, or successor
program(s), in accordance with CMS payment policies.
13.30.21 Room and board
• The following are included in daily hospital
service acute care and should not be billed as
separate items to BCBSNC or its members:
‡ Room and complete linen service
‡ Dietary service: meals, therapeutic diets,
required nourishment, dietary consultation
and diet exchange list
‡ General nursing services include patient
education such as instruction and materials.
This does not include or refer to private duty
nursing
‡ All equipment needed to weigh the patient
(e.g., scales)
‡ Thermometers, blood pressure apparatus,
gloves, tongue depressors, cotton balls and
other items typically used in the examination
of patients
‡ Use of examining and/or treatment rooms for
routine examination
‡ Routine supplies as a part of normal patient
care
‡ Administration of enemas and medications
including IVs
‡ Postpartum services
‡ Recreation therapy
‡ Enterostomal therapy (the costs of enterostomal
supplies are covered ancillary items)
13.30.22 Special beds
• Bill these beds using UB-04 revenue codes R946
and R947.
• The following beds are covered as a separate
charge when medically necessary:
‡ Bio-Dyne bed
‡ Clinitron bed
‡ Flexicare bed
‡ Fluidair bed
‡ Just Step mattress
‡ Ken-Air bed
‡ Kinetic therapy bed
‡ Pegasus airwave system
‡ Restcue bed (Hill-Rom EFICA CC)
‡ Roto-Rest bed
‡ Therapulse bed
13.30.23 Special monitoring equipment
• Includes dinemapp, swan ganz, cardiac,
pressure monitor and telemetry.
• Charges include the use of supplies (e.g.,
electrodes, guidewires and telemetry pouches).
• When special monitoring equipment is used by
a patient in routine or general accommodations,
a separate monitoring equipment charge may
be billed.
• When a patient is using special monitoring
equipment in the operating room, recovery
room or anesthesia department and is
transported to another ancillary department or a
room, a separate monitoring equipment charge
should not be billed.
• Monitoring equipment used during transport is
considered a continuation of services.
• Set up fees that only represent personnel time
are considered part of the procedure/treatment
fee.
PAGE 13-48
Chapter 13
Claims billing and reimbursement
13.30.24 Speech therapy
• Covered speech therapy services should be
billed using UB-04 revenue code R440-R449.
13.30.25 Take-home drugs
• BCBSNC certificates do not provide basic
inpatient hospital benefits for take-home drugs.
• The itemization must be submitted on the claim.
• Speech therapy is covered only when used to
restore function following surgery, trauma or
stroke.
• Speech therapy is not considered medically
necessary treatment for the following diagnoses:
‡ Attention disorder
‡ Behavior problems
‡ Conceptual handicap
‡ Mental retardation
‡ Psychosocial speech delay
‡ Developmental delay
13.30.26 Take-home supplies
• Covered take-home supplies should be billed
using UB-04 revenue code R273.
• BCBSNC certificates do not provide basic
inpatient hospital benefits for take-home items.
• Benefits are provided for take-home items by
major medical and extended benefits when
these items are properly identified on the claim.
• To be considered eligible for coverage,
speech therapy services must be delivered
by a qualified provider of speech therapy
services. A qualified provider is one who
is licensed where required and is
performing within the scope of the license.
PAGE 13-49
Chapter 14
Pharmacy and specialty
networks
Chapter 14
Pharmacy and specialty networks
14.1
The BCBSNC formulary
14.1.1 BCBSNC formulary medications
BCBSNC formulary is a list of drugs selected by
BCBSNC in consultation with a team of health care
providers, which represents the prescription
therapies believed to be a necessary part of a
quality treatment program. BCBSNC will generally
cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled
at a BCBSNC network pharmacy, meets the definition
of a Part D drug and other plan rules are followed.
14.1.2 Formulary changes/updates
To get updated information about the drugs
covered by BCBSNC Medicare prescription drug
coverage, please visit our Web site at bcbsnc.com/
content/providers/blue-medicare-providers/
index.htm or call customer service at 1-888-2969790, Monday - Friday, 8 a.m. to 6 p.m. An online
drug search can be accessed from bcbsnc.com/
content/providers/blue-medicare-providers/
index.htm and a printable version of the formulary
is also available.
BCBSNC may add or remove drugs from our
formulary during the year. If we remove drugs from
our formulary, add prior authorization, quantity limits
and/or step therapy restrictions on a drug (or move
a drug to a higher cost-sharing tier), we must notify
members who take the drug that it will be removed
at least sixty (60) days before the date that the
change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a sixty (60) day supply of
the drug. If the Food and Drug Administration
deems a drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from the
market, we will immediately remove the drug from
our formulary and provide notice to members who
take the drug.
To request a copy of the BCBSNC Medicare
prescription Standard or Enhanced plan formulary,
please contact customer service at 1-888-296-9790
or you may visit our Web site at bcbsnc.com/
content/providers/blue-medicare-providers/
index.htm.
14.1.3 Generic substitution policy
Most drugs which have generic equivalents are
covered only at a generic reimbursement level.
Prescribing generic drugs when available can mean
significant savings for your patients, and may
improve adherence to chronic drug regimens.
14.1.4 Prior authorization
BCBSNC requires prior authorization for certain
drugs. Physicians on behalf of members may
request prior authorization for these drugs.
Designations that prior authorizations are required
are indicated on the online drug search and
printable formulary. Prior authorization criteria are
posted at bcbsnc.com/content/providers/bluemedicare-providers/index.htm.
• For these drugs, prior authorization must be
obtained prior to drug coverage at the pharmacy.
• The physician or the physician’s representative
must contact BCBSNC to request prior
authorization.
• Within the timeline required by BCBSNC, the
physician must supply a clinical supporting
statement that demonstrates that the use of the
drug meets criteria.
14.1.5 Non-formulary requests
Non-formulary drug requests require members to
use the drug for a medically acceptable use and, in
general, to have tried and failed formulary
alternatives in the same drug class. For non-formulary
requests, the member or the member’s prescribing
physician may contact BCBSNC. A physician’s
supporting statement is required for all requests
before the prescription can be approved for
payment. Tier exceptions cannot be granted for
non-formulary drugs. Physicians may contact the
Plan by calling BCBSNC at 1-888-296-9790 or
using the applicable fax request form to request an
exception.
PAGE 14-1
Chapter 14
Pharmacy and specialty networks
BCBSNC pharmacy fax forms can be accessed via
the Web at bcbsnc.com/content/medicare/
member/policies/approval.htm.
Medicare Advantage
Prescription drug plan prior authorization requests
and non-formulary drug requests:
Fax number: 1-888-446-8535
Address:
Blue Cross and Blue Shield of North Carolina
Attention: Exceptions - Health Care Services
PO Box 17509
Winston-Salem, NC 27116-7509
Provider Telephone: 1-888-296-9790
14.1.6 Quantity limits
For certain drugs, BCBSNC limits the amount of the
drug covered. For example, BCBSNC provides nine
(9) tablets per thirty (30) days for prescriptions for
sumatriptan 100mg tablets. If a patient requires a
quantity in excess of the quantity limit for a specific
drug strength, the physician must supply a statement
supporting the clinical need for the higher quantity
and any additional therapies being used to treat the
patient’s medical condition.
14.1.7 Step therapy
In some cases, patients are required to first try one
(1) drug to treat their condition before another drug
is covered for that condition. If a prerequisite drug is
not found in recent past claims, a drug requiring
step therapy is not covered. The physician or
physician’s representative, on the patient’s behalf,
may contact BCBSNC to request an exception. A
clinical supporting statement will be required stating
that the patient has a documented intolerance,
contraindication or hypersensitivity to the prerequisite
drug(s), plus any additional clinical information
regarding the patient’s need for the step therapy
drug.
14.1.8 Drugs with Part B and D coverage
Some drugs can be covered under either Part B or
Part D depending on the circumstances. Drugs that
are currently authorized by law as covered under
Part B will remain covered under Part B and should
be billed to the Part B payer. For information about
drugs covered under Part B, visit the CMS coverage
database or DME-MAC Jurisdiction C Web page.
14.1.9 Request for drugs to be added to the
formulary
To request an addition to the formulary, physicians
may forward a written request indicating the
advantage of the drug over current formulary
medications to:
Blue Cross and Blue Shield of North Carolina
PO Box 17168
Winston-Salem, NC 27116-7509
14.1.10 Exceptions process
BCBSNC provides a process for situations when a
member demonstrates a medical need for BCBSNC
Medicare Advantage Prescription Drug Plan (MAPD)
to make an exception to its Standard plan terms. A
member, member’s authorized representative, or
member’s prescribing physician may request an
exception in one (1) of the following situations:
• Coverage of a drug not on the formulary (list of
drugs the plan covers) or that requires step therapy
• Continued coverage of a drug that has been
removed from the formulary for reasons other
than safety or because the Part D prescription
drug was withdrawn from the market by the
drug’s manufacturer.
• Coverage of a drug requiring prior authorization
• Exceptions to quantity limits
To request an exception to the coverage rules for
the member’s Medicare prescription drug plan, the
member or the member’s prescribing physician may
call or submit a written request.
PAGE 14-2
Chapter 14
Pharmacy and specialty networks
The prescribing physician must provide a supporting
statement that the exception is medically necessary
to treat the enrollee’s disease or medical condition.
Care Management & Operations will review the
exception request and make a determination as
expeditiously as the member’s health requires, but
no later than seventy-two (72) hours from the date
we receive the request. The member and the
member’s prescribing physician will be given notice
of the coverage determination. If the decision is not
in the member’s favor, the notice must be given
orally followed within three (3) days by a written
notice which includes notification of the appeals and
grievance processes to be followed if the member is
dissatisfied with our decision.
2. Our Plan cannot cover a drug purchased
outside the United States and its territories.
3. Our Plan usually cannot cover off-label use.
“Off-label use” is any use of the drug other
than those indicated on a drug's label as
approved by the Food and Drug Administration.
Generally, coverage for “off-label use” is allowed
only when the use is supported by certain reference
books.
These reference books are:
The American Hospital Formulary Service Drug
Information, The DRUGDEX Information System,
and the USPDI or its successor.
Physicians may request an exception by calling,
faxing, or writing to health services:
If the use is not supported by any of these reference
books, then our plan cannot cover its “off-label use.”
Telephone: 1-888-296-9790
Also, by law, these categories of drugs are not
covered by Medicare drug plans:
Fax: 1-888-446-8535
Written requests:
Blue Medicare HMOSM
Attention:
Exceptions - Care Management & Operations
PO Box 17509
Winston-Salem, NC 27116-7509
Members may request an exception by calling the
customer service department or may send a written
request to:
Blue Medicare HMOSM
Attention:
Exceptions - Care Management & Operations
PO Box 17509
Winston-Salem, NC 27116-7509
Members should refer to their evidence of coverage
for more details on the exception process.
14.1.11 Types of drugs not covered by
prescription drug plan
Three general rules about drugs that Medicare drug
plans will not cover under Part D:
• Non-prescription drugs (also called over-thecounter drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold
symptoms
• Drugs when used for cosmetic purposes or to
promote hair growth
• Prescription vitamins and mineral products,
except prenatal vitamins and fluoride
preparations
• Drugs when used for the treatment of sexual or
erectile dysfunction, such as Viagra, Cialis,
Levitra, and Caverject
• Drugs when used for treatment of anorexia,
weight loss, or weight gain
• Outpatient drugs for which the manufacturer
seeks to require that associated tests or
monitoring services be purchased exclusively
from the manufacturer as a condition of sale
1. Part D drug coverage cannot cover a drug that
would be covered under Medicare Part A or
Part B.
PAGE 14-3
Chapter 14
Pharmacy and specialty networks
14.1.12 Medication therapy management
program
Members enrolled in Blue Medicare HMOSM and
Blue Medicare PPOSM plans with Medicare
prescription drug benefits or Blue Medicare Rx may
be eligible for the Medication Therapy Management
Program (MTMP), in accordance with CMS
requirements. The purpose of the program is to
provide medication therapy management services
to targeted members. These services are designed
to ensure that covered Part D drugs are appropriately
used to optimize therapeutic outcomes by improving
medication use and reducing the risk of adverse
drug events including adverse drug interactions.
The MTMP is developed in cooperation with licensed
and practicing pharmacists and physicians.
The goals of the program are to educate members
regarding their medications, increase member
adherence to medication therapy, and identify and
prevent medical complications related to
medication therapy.
Individual members eligible for the MTMP services
must meet all three (3) criteria:
• Have at least three (3) of the following chronic
diseases: diabetes, chronic obstructive
pulmonary disease, asthma, hypertension,
dyslipidemia, congestive heart failure,
osteoporosis, osteoarthritis or depression.
• Have claims for a minimum of six (6) different
chronic/maintenance Part D covered
medications.
• Are likely to incur annual costs for covered Part
D medications that exceed $3,138 in the year
2015 or as specified by CMS annually.
Eligible members are automatically enrolled in the
program. A letter and participation form will be
mailed to the eligible members informing them of
their enrollment in the program. Participation in the
program is voluntary and the program and services
are provided at no additional cost to the member.
Members are encouraged to return the participation
form in the envelope provided or call a toll-free
number (1-866-686-2223 or TTY users call 711 or
1-800-855-2881) between 10 a.m. and 6 p.m.
eastern time, Monday thru Friday.
MTM services include the following interventions for
members and prescribers:
• An annual Comprehensive Medication Review
(CMR) which includes an interactive, person-toperson consultation via the telephone between
the member and the pharmacist or nurse. The
purpose of the CMR is to review all prescription
and non-prescription medications the member
is taking, provide education on their medications,
identify care gaps and patterns of underuse or
overuse and medication safety issues. After the
CMR, the member is mailed a personalized
medication list to carry to his provider visits as
well as a summary of what was discussed.
• Quarterly targeted medication reviews (completed
electronically based on prescribed medications).
Member’s prescribers may be sent a letter about
specific medication-related problems or about
opportunities to optimize medication use.
14.2
Medication management programs
14.2.1 High Risk Medications in the elderly
The use of High Risk Medications (HRM) in the
Elderly (adults over age sixty-five [65]) is an NCQA,
HEDIS, and CMS quality measure. The High Risk
Medications program goal is to reduce the
utilization of high risk medications in the older
patient which may place them at risk for an adverse
drug-related event.
Through our claims database, Blue Medicare
identifies members with recent prescriptions for a
drug considered to be a high risk medication. Based
on this information, we may send a letter to the
member’s provider or most recent prescriber asking
them to evaluate whether the drug is still
appropriate. Some of the drugs included on high
risk medication list are not necessarily
contraindicated in the elderly but recommendations
are to consider formulary alternatives that would
place an older member at less of a safety risk.
PAGE 14-4
Chapter 14
Pharmacy and specialty networks
Examples of High Risk Medications for adults over
age sixty-five (65) include the following classes of
drugs: first-generation or older antihistamines,
skeletal muscle relaxants, estrogens, nonbenzodiazepine hypnotics for greater than ninety
(90) days, and nitrofurantoin for greater than
ninety (90) days.
14.2.2 Medication Adherence
Medication Adherence is a program that monitors
prescription claims for members and identifies those
members whose adherence to a chronic maintenance
medication falls below the 80% threshold based on
prescription drug claims data. Blue Medicare may
send a letter to the prescriber notifying them that a
member has a gap in their refill history so that you
can discuss this with your patient. In addition, a
member may receive a phone call or mailing with an
educational message about the importance of taking
their medications to their health.
Examples of medications monitored through this
program are Antiretroviral medications, oral
diabetes medications, renin angiotensin blockers,
and statins.
14.3
Medical eye care
BCBSNC is contracted with Community Eye Care to
provide medical/routine vision care to BCBSNC
members using a panel of optometrists and
ophthalmologists.
• No referral needed
14.4
Mental health/substance abuse
management programs
Mental health and substance abuse services do not
require a referral from the primary care physician.
BCBSNC delegates mental health and substance
management and administration (including
certification, concurrent review, discharge planning
and case management) to Magellan Behavioral
Health. Contact Magellan Behavioral Health to
conduct full utilization management for mental health
and substance abuse services at 1-800-359-2422.
14.5
Laboratory services
Reference labs:
If a specimen is drawn and the laboratory work is
sent to a reference lab, the only services billable to
BCBSNC is the administrative/handling charge
(i.e., 36415 - Venipuncture). The reference lab will
bill directly to BCBSNC for the services it provides.
In-office labs:
If you are performing the laboratory service in your
office, and your lab is CLIA certified, the services
can be filed directly with BCBSNC for reimbursement.
Selected counties are subject to BCBSNC laboratory
office allowable lists. Under that program only
procedures included in the appropriate office
allowable lists can be billed directly to BCBSNC.
Questions regarding this lab program should be
directed to your Network Management
representative.
• Direct access to contracting ophthalmologists
and optometrists
• Routine vision
• Medical surgical
Community Eye Care 1-888-254-4290
PAGE 14-5
Chapter 14
Pharmacy and specialty networks
14.6
BCBSNC office laboratory allowable list
If you are performing laboratory service in your office and your lab is Clinical Laboratory Improvement
Amendments (CLIA) certified, many lab services can be filed directly to BCBSNC for reimbursement.
However, services identified by Medicare as “CLIA Excluded” or “CLIA Waiver,” are not eligible for
reimbursement by BCBSNC unless you have provided BCBSNC evidence in advance of having obtained the
CLIA certification necessary for billing these services, as CLIA approved for your laboratory.
Prior to performing in-office laboratory services, providers are encouraged to verify their laboratory CLIA
certification and review the BCBSNC allowable service code list that’s applicable to their laboratory CLIA
certification. BCBSNC currently maintains allowable service code lists, which display the in-office lab services
a provider may bill BCBSNC. These lists are available on the ‘Blue Medicare Providers’ pages of our Web site
bcbsnc.com.
PAGE 14-6
Chapter 15
Post-service provider
appeals
Chapter 15
Post-service provider appeals
15.1
Level I post-service provider
appeals
Post-service provider appeals consist of retrospective
claim reviews and do not require a member signed
authorization. Post-service provider appeals are
performed based on your belief that a claim has
been denied or adjudicated incorrectly.
The post-service provider appeal process is separate
from the member appeals and grievance process
and is listed in Chapter 16 of this provider manual.
If at any time the member files a post-service claim
appeal during the review of a provider appeal, the
member’s appeal supersedes the provider appeal.
Providers may not appeal items related to member
benefit or contractual issues on their own behalf.
Post-service provider appeals for review of a
processed claim may be submitted for the following
reasons:
• Coding/bundling, or fees
• Cosmetic
• Experimental/investigational
• Financial recovery (available to physicians,
physician groups and physician organizations
only)
• Global period denial
• No authorization for inpatient admission
• Non-contracted provider payment dispute
• Not medical necessary
• Re-bundling
• Services not eligible for separate reimbursement
Level I post-service provider appeals for billing/
coding disputes and medical necessity
determinations are handled by BCBSNC and are
available to physicians, physician groups, physician
organizations and facilities. Providers have (ninety)
90 calendar days from the claim adjudication date
to submit a Level I post-service provider appeal for
billing/coding disputes and medical necessity
determinations for claims adjudicated on and after
April 1, 2010.
Level I financial recovery physician appeals are
handled by BCBSNC and are available to physicians,
physician groups and physician organizations.
Physicians, physician groups and physician
organizations will have thirty (30) calendar days from
the date of the invoice or demand letter to submit
the Level I financial recovery appeal for refund
requests requested on and after April 1, 2010. To
request a review, contact BCBSNC using one (1) of
the following methods:
• Call the Provider Blue LineSM at 1-888-296-9790
• Complete the Level I Appeal Form for Blue
Medicare HMOSM and Blue Medicare PPOSM
available to copy from the Forms section of this
manual and for download from the bcbsnc.com
Web site located at bcbsnc.com/content/
providers/appeals/index.htm (when sending
to BCBSNC, include objective medical
documentation).
• Mail a letter of explanation, including objective
medical documentation, to the following address:
Blue Cross and Blue Shield of North Carolina
Provider Appeals Unit
Blue Medicare HMOSM and Blue Medicare PPOSM
PO Box 17509
Winston-Salem, NC 27116-7509
• Fax your inquiries to:
Provider Appeals Unit: 919-287-8815
All inquiries regarding the status of an appeal
should be routed through customer service.
Level I post-service provider appeals are handled
within thirty (30) days from the date of receipt of all
information. Supporting objective medical
documentation should be submitted for post-service
provider appeal reviews.
15.2
Level II post-service provider
appeals
Level II post-service provider appeals are available to
physicians, physician groups, and physician.
PAGE 15-1
Chapter 15
Post-service provider appeals
Organizations and will be performed by an
independent review organization. Physicians,
physician groups, and physician organizations may
file a Level II post-service provider appeal for
medical necessity or billing disputes with MES
Solutions, an independent review organization.
There is a filing fee associated with all requests for a
Level II post-service provider appeal.
15.2.1 Process for submitting a Level II
post-service provider appeal
The Level II post-service provider appeal requests
should clearly identify the issue that is in dispute
and rationale for the appeal. Demographic
information including subscriber name, patient
name, patient BCBSNC ID number, provider name,
and provider ID number should also be included
with any request for appeal. Level II post-service
provider appeals require a filing fee to be submitted
before the review can begin.
A physician, physician group, or physician
organization may file a Level II post-service provider
appeal if an adverse determination was given on a
Level I post-service provider appeal billing dispute
or medical necessity denial, as described below.
15.2.2 Level II post-service provider appeal
for billing disputes
The BCBSNC billing dispute resolution process is
available to resolve disputes over the application of
coding and payment rules and methodologies to
specific patients. Physicians, physician groups, or
physician organizations must submit a written
request for Level II post-service provider billing
dispute appeal within ninety (90) calendar days of
the date of the Level I post-service provider appeal
denial letter.
Physicians, physician groups, or physician
organizations must exhaust BCBSNC’s Level I postservice provider appeal process before submitting a
Level II post-service provider appeal. A physician,
physician group, or physician organization is
deemed to have exhausted BCBSNC’s Level I postservice provider appeal process if BCBSNC does not
communicate a decision within thirty (30) calendar
days of BCBSNC’s receipt of all documentation
reasonably needed to make a determination on the
Level I post-service provider appeal.
Physicians, physician groups, or physician
organizations should contact MES Solutions directly
to submit a Level II post-service provider appeal for
a billing dispute.
Mailing Address:
MES Solutions
BDRP Department
100 Morse Street
Norwood, MA 02062
Phone: 800-437-8583
Fax: 888-868-2087
www.mesgroup.com
A request submitted online through the MES Web
site, requires new user registration. Once
registered, the user should sign-in and select the
Love Settlement link to proceed with their request.
Level II provider appeals for billing disputes
administered by an independent review
organization, will be reviewed based on the
information previously submitted with the Level I
provider appeal. BCBSNC will supply all
documentation from the Level I provider appeal to
the billing dispute reviewer. For additional
questions, please contact MES Solutions directly.
15.2.3 Level II post-service provider appeal
for medical necessity
Level II post-service provider appeals are available
to physicians, physician groups, and physician
organizations to resolve disputes over the denial of
investigational, experimental, cosmetic, and medical
necessity determinations.
Physicians, physician groups, or physician
organizations must submit a written request for a
Level II post-service provider medical necessity
appeal within sixty (60) calendar days of the date of
the Level I post-service provider appeal denial letter.
Physicians, physician groups, or physician
organizations must exhaust BCBSNC Level I postservice provider appeal process before submitting a
Level II post-service provider appeal.
PAGE 15-2
Chapter 15
Post-service provider appeals
Physicians, physician groups, or physician organizations should contact MES Solutions directly to submit a
Level II post-service provider appeal for medical necessity.
Mailing Address:
MES Solutions
Love Settlement Department
100 Morse Street
Norwood, MA 02062
Phone: 800-437-8583 • Fax: 888-868-2087
www.mesgroup.com
A request submitted online through the MES Web site, requires new user registration. Once registered, the
user should sign-in and select the Love Settlement link to proceed with their request. Level II post-service
provider appeals for medical necessity administered by an independent review organization, will be reviewed
based on the information previously submitted with the Level I post-service provider appeal. BCBSNC will
supply all documentation from the Level I post-service provider appeal to the billing dispute reviewer. For
additional questions, please contact MES Solutions directly.
15.2.4 Filing fee matrix
Billing dispute
Amount of dispute
Filing fee calculation
$1000 or less
Filing fee shall be equal to $50
Greater than $1000
Filing fee shall be equal to $50 plus 5% of the amount by which the amount
in dispute exceeds $1000 but in no event shall the fee be greater than 50%
of the cost of the review.
Medical necessity dispute
Amount of dispute
Filing fee calculation
$1000 or less
Filing fee shall be equal to $50
Greater than $1000
Filing fee shall be equal to $250
Billing disputant of dispute
Note: For Level II post-service provider appeals related to billing disputes, the disputed amount must exceed
$500.00. In instances where the disputed amount is less than $500, the physician, physician group, or
physician organization may submit similar disputes to the independent review organization within one (1) year
of the original submission date. If the physician, physician group, or physician organization intends to submit
additional similar disputes during the year, the physician must contact the billing dispute reviewer to notify
that additional similar submissions will be sent. If the one (1) year lapses and the disputes submitted are not in
excess of $500 in the aggregate, the original dispute will be dismissed.
The filing fee will be refunded in the event that the physician, physician group, or physician organization
prevails in the Level II post-service appeal process.
PAGE 15-3
Chapter 16
Member appeal and
grievance procedures
Chapter 16
Member appeal and grievance procedures
16.1
Member complaints, grievances
and appeals
BCBSNC members are encouraged to let BCBSNC
know if they have questions, concerns or problems
related to covered services or the care they receive.
Members are also encouraged to first attempt to
resolve issues about treatment though his/her
primary care physician. If the member’s issue cannot
be resolved in this manner, the member has the
right to file a formal complaint with BCBSNC.
16.2
What is an appeal?
An appeal is a request to change a coverage
decision about what services are covered or what
we will pay for a service. Appeals must be filed
within sixty (60) calendar days from the date of the
written denial notice. Each denial notice will include
information on the member’s right to file an appeal
or grievance with instructions on how to do so.
Once BCBSNC receives an appeal or grievance, it is
handled through the mandated CMS appeal or
grievance process.
16.3
Who can file an appeal?
For a standard appeal, only a member or their
authorized representative has the right to file an
appeal through a formal process. If someone other
than the member requests to file a standard appeal,
the request is not valid until the member and the
requesting party sign an appointment of
representative form. A standard appeal must be
in writing.
For expedited or fast appeals, the member’s
physician can file the appeal in addition to the
member or their authorized representative. A fast
appeal is usually filed orally or by fax.
16.4
How quickly does BCBSNC handle
an appeal?
CMS states that all appeals must be handled as
quickly as the member’s health requires. However,
there are specific, maximum timeframes for handling
the different types of appeals. For example:
• An appeal of a medical claim denial must be
handled within sixty (60) calendar days after we
receive the request.
• An appeal of a medical service denial must be
handled within thirty (30) calendar days after we
receive the request unless an expedited or fast
appeal is requested. An expedited appeal must
be handled within seventy-two (72) hours.
• An appeal of a prescription drug denial must be
handled within seven (7) calendar days unless an
expedited or fast appeal is requested. An
expedited prescription drug appeal must be
handled within seventy-two (72) hours.
16.5
What is a grievance?
A grievance is a type of complaint that is made if a
member is dissatisfied with any aspect of BCBSNC
or with service or quality of care rendered by a
contracting provider.
Only the member or his/her authorized representative
may file a grievance. BCBSNC will respond to a
written grievance within thirty (30) calendar days
after we receive the written complaint.
Complaints from members about contracting
providers may relate to a provider’s compliance with
BCBSNC procedures, personal relations between
providers and members, access to medical care,
service issues with the provider’s office, or potential
medical quality problems.
All complaints about providers are documented and
placed in the provider’s file for trending and review
during credentialing. Every quality of care grievance
is reviewed by a plan Medical Director who will
decide if further investigation with the provider in
question is indicated.
PAGE 16-1
Chapter 16
Member appeal and grievance procedures
16.6
What involvement does a contracting physician have with an appeal?
A contracting physician can be involved in an appeal in several ways:
• If a member files an appeal, he/she may ask their physician for support by asking the physician to write a
letter on their behalf.
• BCBSNC may contact the physician’s office to obtain additional medical records for review during the
appeal process. Quick compliance with this request is necessary as BCBSNC is required to handle a
service appeal as quickly as the member’s health requires. If the case is forwarded to MAXIMUS CHDR,
CMS’s contracted independent review entity for a decision, CHDR will ask for medical records if they do
not believe all records have been submitted to them. Again, the requested records will need to be
provided expeditiously.
• If a member’s physician believes a member’s situation is time sensitive, the physician (not his/her staff)
may file a fast appeal on the member’s behalf. The physician can do this by calling BCBSNC customer
services or Care Management & Operations departments, or by faxing a fast appeal request to
1-336-794-8836.
Please note that neither the mandated CMS appeals process nor the grievance process is available to
providers who have a dispute with BCBSNC over payment of a claim or over a contractual denial.
See Chapter 13.13, Claims reimbursement disputes for how to request a review of a claim or contractual
denial for which the member has no financial liability.
PAGE 16-2
Chapter 17
Member rights and
responsibilities
Chapter 17
Member rights and responsibilities
BCBSNC is committed to informing the providers of Blue Medicare HMOSM of the member’s rights and
responsibilities.
17.1
Member rights
1) You have the right to be treated with respect, dignity and consideration for your privacy by health care
providers and by BCBSNC staff.
2) You have the right to receive information about the Plan, its services, its health care providers and your
rights and responsibilities as a member of the Plan.
3) You have the right to private, confidential treatment of your records by Plan staff and providers, and you
have the right to access your medical records by contacting the provider of service.
4) You have the right to accessible services from the Plan and from providers of health care, regardless of
your English proficiency, reading skill, cultural or ethnic background, and/or physical or mental disabilities.
5) You have the right to receive medically necessary services as described in your BCBSNC Blue Medicare
HMOSM certificate of coverage agreement.
6) You have the right to coverage for emergency and urgently needed care without prior authorization using prudent
layperson standards outlined in your certificate of coverage. (Refer to the certificate of coverage for details.)
7) You have the right to a second opinion if you question a contracting provider’s decision about the need
for surgery. A list of contracting providers can be found in the provider directory. With authorization from
either your primary care physician or the Plan a second opinion from the provider you select is covered.
8) You have the right to prompt resolution of any problems or complaints regarding BCBSNC Blue Medicare
HMOSM or contracting providers via the Plan’s grievance process. You have a right to prompt resolution of
any request for reconsideration or pre-service or claim denials via the Medicare appeals process. Questions
about benefits, claims payment, contracting providers, Plan services or the appeals and grievance
procedures referenced above should be directed to a Blue Medicare HMOSM customer service
representative by calling 1-888-310-4110 or 1-888-451-9957 (TDD/TTY).
9) You have the right to disenroll from Blue Medicare HMO,SM within guidelines governing restriction of
election changes beginning 1/1/02, by giving written notice to the Plan of your intent to do so. Coverage
will end on the first day of the month following the receipt of your request. To end your coverage, you
may either: (a) send written notice to BCBSNC Blue Medicare HMO,SM PO Box 17509, Winston-Salem, NC
27116-7509; or (b) disenroll at any Social Security Administration Office or Railroad Retirement Board Office.
10) You have the right to continue coverage with Blue Medicare HMO,SM except in the following situations:
(a) non-payment of Plan premiums, (b) fraud, (c) abuse of the organization’s membership card,
(d) permanent moves outside the Blue Medicare HMOSM service area, (e) loss of Medicare entitlement,
or (f) “for cause” subject to CMS approval.
11) You have the right to participate with providers in making decisions about your health care and to receive
information on available treatment options (including no treatment) or alternative courses of care. In
addition, you have the right to designate someone to make your health care decisions for you in the event
you are unable to make these decisions yourself. (These are known as advance directives. For more
information, ask your primary care physician.)
12) You have the right to receive the services of the Blue Medicare HMOSM primary care physician of your
choice. Your choice of PCP must be reported to and recorded by the Plan. Your PCP is required to provide
or arrange care twenty-four (24) hours a day, seven (7) days a week.
PAGE 17-1
Chapter 17
Member rights and responsibilities
17.2
Member responsibilities
1) It is your responsibility to select a primary care physician and have all your medical care provided by or
arranged by your PCP except for emergency or urgently needed care. Blue Medicare HMOSM does not
cover services which you arrange on your own except for emergencies and urgently needed care or as
specified in your certificate of coverage.
2) In the event of an emergency, go to the nearest emergency room or call 911 for assistance. We ask that
you notify your PCP within forty-eight (48) hours or as soon as possible if you seek emergency care so
that he or she can arrange for appropriate follow-up care. If you are out of the service area and require
urgently needed care, we request that you, if possible, first telephone your PCP and then seek care from
an appropriate local medical facility, according to your PCP’s instructions. (Refer to the certificate of
coverage for details.)
3) It is your responsibility to make monthly Plan premium payments for your coverage on or before the first
day of the month of coverage, unless your employer/retiree group makes these payments on your behalf.
If the premium is not paid on time, we will send you notice of late payment, indicating that your Blue
Medicare HMOSM coverage may be ended according to our Blue Medicare HMOSM payment guidelines.
For more Plan payment information, call customer service at 1-888-310-4110 or 1-888-451-9957 (TDD/TTY).
4) It is your responsibility to inform us of changes in name, address and telephone number, PCP selection, etc.
5) It is your responsibility to pay any required copayments when they are requested of you, such as
copayments for office visits.
6) It is your responsibility to pay for any service that is not covered under the Plan. This includes services
which are excluded from coverage, services obtained from a specialist without referral from your PCP
(except in instances where direct access is available), and services obtained from non-Plan providers
without prior authorization.
7) It is your responsibility to notify the Plan if you move out of the Blue Medicare HMOSM service area.
According to Medicare regulations, persons who live outside of the BCBSNC Blue Medicare HMOSM
service area are not eligible to continue enrollment in BCBSNC.
8) It is your responsibility to keep appointments or follow procedures to avoid missed appointment charges.
9) It is your responsibility to understand how the Plan works and follow Plan procedures. This includes
understanding the referral process to avoid unauthorized, noncovered services.
10) It is your responsibility to supply health care providers information needed to provide adequate care, and
to follow treatment advice given by those providing health care services.
11) It is your responsibility to consult with your primary care physician in all matters regarding your health care.
This includes contacting your primary care physician for instructions on care after regular office hours,
except for emergency or urgently needed care.
Inquiries regarding member rights and responsibilities should be directed to the Blue Medicare HMOSM
customer service department at 1-336-774-5410 or 1-888-310-4110 or 1-888-451-9957 (TDD/TTY),
Monday-Friday from 8:00 am to 6:00 pm. You may also write to:
Blue Medicare HMOSM
Blue Cross and Blue Shield of North Carolina
PO Box 17509
Winston-Salem, NC 27116-7509
PAGE 17-2
Chapter 18
Sanction process
Chapter 18
Sanction process
18.1
Grievance procedure/sanction
process
There are times when immediate action must be
taken to terminate a provider’s contract in order to
maintain the integrity of the network and/or to
maintain the availability of quality medical care for
members. Reasons justifying immediate terminations
are specified in the provider’s contract, and may
include:
• Loss of license to practice (revocation or
suspension)
• Loss of accreditation or liability insurance
• Suspension or termination of admitting or
practice privileges of a participating physician
• Actions taken by a court of law, regulatory
agency or any professional organization which,
if successful, would materially impair the
provider’s ability to carry out the duties under
the contract
• Insolvency, bankruptcy or dissolution of a practice
Upon receipt of notification of these actions the
affected provider will be notified of the Plan’s intent
to terminate him or her from the network. In
addition to the circumstances outlined above, other
information may be received regarding a network
provider which may impact the participation status
of that physician. This would include reports on
providers describing serious quality of care
deficiencies. Whenever information of this nature is
received, it is evaluated through the normal
credentialing review process which includes review
and recommendation by our credentialing committee.
18.2
Provider notice of termination for
recredentialing
18.2.1 Level I appeal
If the credentialing committee’s recommendation is
to terminate a provider from the network for
documented quality deficiencies or failure to comply
with recredentialing policies and procedures, the
provider file is forwarded for an expedient review by
law and regulatory affairs.
• The provider is formally notified, via certified
mail, of our intent to terminate and the specific
reason for the proposed action. The provider is
informed of his or her right to appeal.
• The provider may request a Level I appeal by
providing additional written documentation
which may include further explanation of facts,
office or other medical records or other
pertinent documentation within thirty (30) days
from the date or the initial notification of
termination.
• Our credentialing committee will review the
additional information provided and make a
recommendation to either uphold or reverse the
original determination. The provider will be
notified via certified mail of the decision and of
his or her right to request a Level II appeal if the
decision is unchanged.
PAGE 18-1
Chapter 18
Sanction process
18.2.2 Level II appeal
A request for a Level II appeal must be made within
fifteen (15) days of the date of the certified letter
from the results of the Level I appeal.
Practitioners requesting hearings within the specified
timeframe will be sent an acknowledgement letter
within five (5) days giving notice as to the date, time
and location of the hearing. The date of the hearing
should not be less than thirty (30) days after the date
of the notice.
A list of witnesses (if any) expected to testify on
behalf of BCBSNC’s credentialing committee should
be given to the practitioner and similar information
requested from the practitioner, i.e., notice of
representation, witness(es).
BCBSNC will determine if the hearing will be held
before an arbitrator mutually acceptable to the
provider and the Plan, before a hearing officer who
is appointed by the Plan and is not in direct
economic competition with the practitioner involved.
A description of the formal hearing process includes,
but is not limited to, the following:
• Representation: The practitioner/provider and
the Plan may be represented by counsel or
other person of their choice.
• Court reporter: BCBSNC may arrange for a
court recorder to provide a record of the
hearing. If BCBSNC does not arrange for a court
recorder, it will arrange for an audio-taped
record to be made of the hearing. Copies of this
record will be made available to the practitioner/
provider upon payment of a reasonable charge.
• Hearing officer’s statement of the procedure:
Before evidence or testimony is presented, the
hearing officer of the Level II appeals committee
will announce the purpose of the hearing and
the procedure that will be followed for the
presentation of evidence.
• Presentation of evidence by BCBSNC: The
Plan may present any oral testimony or written
evidence it wants the appeals committee to
consider. The practitioner/provider or his or her
representative will have the opportunity to crossexamine any witness testifying on the Plan’s behalf.
• Presentation of evidence by practitioner/
provider: After the Plan submits its evidence,
the practitioner/provider may present evidence
to rebut or explain the situation or events
described by the Plan. The Plan will have the
opportunity to cross-examine any witness
testifying on the practitioner’s/provider’s behalf.
• Plan rebuttal: The Plan may present additional
witnesses or written evidence to rebut the
practitioner’s/provider’s evidence. The practitioner/
provider will have the opportunity to examine
any additional witnesses testifying on the Plan’s
behalf.
• Summary statements: After the parties have
submitted their evidence, first the Plan and then
the practitioner/provider will have the
opportunity to make a brief closing statement.
In addition parties will have the opportunity to
submit written statements to the appeal
committee. The appeals committee will
establish a reasonable time for the submission
of such statements. Each party submitting a
written statement must provide a copy of the
statement to the other party.
• Examination by the appeals committee:
Throughout the hearing, the appeals committee
may question any witness who testifies.
The right to a hearing may be forfeited if the
practitioner fails, without good cause, to appear. In
the hearing the practitioner has the right to
representation by an attorney or other person of the
practitioner’s choice, to have a record made of the
proceedings, copies of which may be obtained by
the practitioner upon payment of any reasonable
charges associated in preparation thereof, to call,
examine, and cross-examine witnesses, to present
evidence determined to be relevant by the hearing
officer, regardless of its admissibility in a court of
law, and to submit a written statement at the closing
of the hearing. Upon completion of the hearing, the
practitioner involved has the right to receive a
written recommendation of the arbitrator, officer, or
panel, including a statement of the basis for the
recommendation, and to receive a written decision
of the health care entity, including a statement of
the basis for the decision. The practitioner will be
notified via certified letter within five (5) days from
the date of the hearing of the final determination.
PAGE 18-2
Chapter 18
Sanction process
If a request for reconsideration or a formal hearing is not made by the practitioner within thirty (30) days of the
receipt of the initial notification or fifteen (15) days from the receipt of the notification of the Level I appeal
decision, the Plan will assume the provider has forfeited their appeal rights and proceed with the termination
as stated in the initial notification letter. A copy of the original notification will be sent to Network Management
operations to proceed with termination from all networks. Communication will be sent from Network
Management operations to the credentialing manager’s administrative assistant to confirm the termination of
the provider with copies sent to the managers of credentialing complaint will be forwarded to the delegated
practitioner’s credentialing department for follow up. Any actions taken by the delegated practitioner as
follow-up must be documented and a copy forwarded to BCBSNC.
Based on the credentialing committee recommendation to decredential the practitioner, a report is made to
the appropriate licensing board. The report details the disciplinary action taken against the practitioner
resulting in their loss of privileges to participate in the BCBSNC managed care network.
PAGE 18-3
Chapter 19
Credentialing
Chapter 19
Credentialing
19.1
Credentialing/recredentialing
The purpose of credentialing physicians and providers
is to exercise reasonable care in the selection and
retention of competent, participating providers. The
initial credentialing process can take up to sixty (60)
days for completion from the date a completed
application is received by BCBSNC. BCBSNC
facilitates all credentialing activity for BCBSNC. The
BCBSNC credentialing department deems an
application to be complete when all applicable
sections of the uniform application are completed
accurately, along with all required supporting
documentation. This process includes, but is not
limited to, verification and/or examination of:
• North Carolina license
• Uniform application to participate as a health
care practitioner
• DEA
• Sufficient comprehensive general liability and
professional insurance coverage
• Medicare/Medicaid sanctions
• National Practitioner Databank (NPDB)
• Health Care Integrity Protection Databank (HIPDB)
• Hospital privileges or letter stating how patients
are admitted
• Board certification*
• Other pertinent documentation
• In some instances a letter of recommendation
from the chief of staff or department chair may
be required (i.e., if malpractice settlements
exceeding $200,000 and/or two (2) or more
malpractice settlements)
Initial credentialing requires a signed and dated
uniform application to participate as a health care
practitioner and the supporting documentation. Full
instructions by medical specialty along with a copy
of the uniform application can be found on the Web
site bcbsnc.com/content/providers/blue-medicareproviders/index.htm.
All documents should be sent to the BCBSNC
credentialing department for verification and
processing. To ensure that our quality standards are
consistently maintained, providers are recredentialed
every three (3) years.
We require initial credentialing of any practitioner
who seeks reinstatement in any of our networks after
being out-of-network for more than thirty (30) days.
Please note that this is a change from the previous
timeframe of ninety (90) days.
* For physicians that are not board certified, letters of reference
will be required in support of the application.
19.2
Requirements for provider
credentialing and provider rights
BCBSNC follows a documented process governing
contracting and credentialing, does not discriminate
against any classes of health care professionals, and
has policies and procedures which govern the
denial, suspension and termination of provider
contracts. This includes requirements that providers
meet Original Medicare requirements for participation,
when applicable. Qualified providers must have a
Medicare provider number for participation.
Providers are required to meet and to continue to
meet all applicable credentialing standards adopted
or utilized by BCBSNC during the term of their
participation, including the requirement to possess
and maintain a current unrestricted medical license,
hospital privileges (if applicable), and DEA
registration certificate (if applicable). Providers are
required to notify BCBSNC of subsequent changes
in the status of any information relating to provider’s
professional credentials, including a change in the
status of his/her medical license, hospital privileges,
or DEA registration certificate. Providers are required
to participate in and cooperate with BCBSNC
credentialing and recredentialing processes, and to
comply with determinations made pursuant to
the same.
PAGE 19-1
Chapter 19
Credentialing
19.3
Policy for practitioners pending
credentialing
The BCBSNC credentialing department must deem
a practitioner’s credentialing complete and effective
on or before providing service to a BCBSNC
member in order to receive the practitioners
contracted reimbursement for member’s covered
services.
Claims for covered services provided to members
by a nonparticipating practitioner in a participating
provider group will be denied unless pre-approved.
The BCBSNC member will be held harmless,
including any copayments, coinsurance and/or
deductibles.
19.3.1 Credentialing process
Participating practitioners are encouraged to
consider the time required to complete the
credentialing process as you add new practitioners
to your practices. To assist you in maintaining
accessibility in circumstances where your practice,
and/or the new practitioner, is unable to submit the
credentialing application in a timely manner, we
have created a standard operating procedure that
will allow reimbursement for covered services
provided by a nonparticipating practitioner who is
in the process of joining a BCBSNC participating
practice. The following must apply:
• A credentialing application must have been
submitted to BCBSNC and a determination on
such application is pending, and
• The new practitioner must provide covered
services to BCBSNC members under the direct
supervision of a BCBSNC-similarly licensed and
credentialed practitioner at the practice who
sign the medical record related to such treatment
and files the claim under his or her current
provider number, and
• A statement of supervision form is completed
and submitted to BCBSNC Network Management
(the form may be obtained by contacting
Network Management, if needed).
For a copy of the new standard operating procedure
outlining the details of this process, or if you have
questions, please call Network Management for
further assistance (see Chapter 2, Contacting
BCBSNC and general administration).
19.4
Credentialing grievance procedure
There are times when BCBSNC must take
immediate action to terminate a provider’s contract
in order to maintain the integrity of the network
and/or to maintain the availability of quality medical
care for members. Reasons justifying immediate
terminations are specified in the provider’s contract,
and may include:
• Loss of license to practice (revocation or
suspension)
• Loss of accreditation or liability insurance
• Suspension or termination of admitting or
practice privileges of a participating physician
• Actions taken by a court of law, regulatory
agency, or any professional organization which,
if successful, would materially impair the
provider’s ability to carry out the duties under
the contract
• Insolvency, bankruptcy, or dissolution of a
practice
Upon receipt of notification of these actions the
affected provider will be notified of BCBSNC’s intent
to terminate him/her from the network. In addition
to the circumstances outlined above, other
information may be received regarding a network
provider, which may impact the participation status
of that physician. This would include reports on
providers describing serious quality of care
deficiencies. Whenever information of this nature is
received, it is evaluated through the normal
credentialing review process which includes review
and recommendation by our credentialing
committee.
PAGE 19-2
Chapter 19
Credentialing
19.4.1 Provider notice of termination for
recredentialing (Level I appeal)
If the credentialing committee’s recommendation is
to terminate a provider from the network for
documented quality deficiencies or failure to comply
with recredentialing policies and procedures, the
provider file is forwarded for an expedient review by
law and regulatory affairs.
• The provider is formally notified, via certified
mail, of our intent to terminate and the specific
reason for the proposed action. The provider is
informed of his or her right to appeal.
• The provider may request a Level I appeal by
providing additional written documentation
which may include further explanation of facts,
office or other medical records or other
pertinent documentation within thirty (30) days
from the date or the initial notification of
termination.
• Our credentialing committee will review the
additional information provided and make a
recommendation to either uphold or reverse the
original determination. The provider will be
notified via certified mail of the decision and of
his/her right to request a Level II appeal if the
decision is unchanged.
19.4.2 Level II appeal (formal hearing)
A request for a Level II appeal must be made within
fifteen (15) days of the date of the certified letter
from the results of the Level I appeal.
BCBSNC will determine if the hearing will be held
before an arbitrator mutually acceptable to the
provider and the Plan, before a hearing officer who
is appointed by the Plan and is not in direct
economic competition with the practitioner, or
before a panel of Plan appointed individuals not in
direct competition with the practitioner involved.
A description of the formal hearing process
includes, but may not be limited to, the following:
• Representation: The practitioner/provider and
BCBSNC may be represented by counsel or
other person of their choice.
• Court reporter: BCBSNC may arrange for a
court recorder to provide a record of the
hearing. If BCBSNC does not arrange for a court
recorder, it will arrange for an audio-taped
record to be made of the hearing. Copies of this
record will be made available to the practitioner/
provider upon payment of a reasonable charge.
• Hearing officer’s statement of the procedure:
Before evidence or testimony is present, the
hearing officer of the Level II appeals committee
will announce the purpose of the hearing and
the procedure that will be followed for the
presentation of evidence.
• Presentation of evidence by BCBSNC:
BCBSNC may present any oral testimony or
written evidence it wants the appeals committee
to consider. The practitioner/provider or his/her
representative will have the opportunity to
cross-examine any witness testifying on
BCBSNC’s behalf.
Practitioners requesting hearings within the specified
timeframe will be sent an acknowledgement letter
within five (5) days giving notice as to the date, time
and location of the hearing. The date of the hearing
should not be less than thirty (30) days after the date
of the notice.
• Presentation of evidence by practitioner/
provider: After BCBSNC submits its evidence,
the practitioner/provider may present evidence
to rebut or explain the situation or events
described by BCBSNC. BCBSNC will have the
opportunity to cross-examine any witness
testifying on the practitioner’s/provider’s behalf.
A list of witnesses (if any) expected to testify on
behalf of BCBSNC’s credentialing committee should
be given to the practitioner and similar information
requested from the practitioner, i.e., notice of
representation, witness(es).
• BCBSNC rebuttal: BCBSNC may present
additional witnesses or written evidence to
rebut the practitioner’s/provider’s evidence. The
practitioner/provider will have the opportunity
to cross-examine any additional witnesses
testifying on BCBSNC’s behalf.
PAGE 19-3
Chapter 19
Credentialing
• Summary statements: After the parties have
submitted their evidence, first BCBSNC and
then the practitioner/provider will have the
opportunity to make a brief closing statement.
In addition, the parties will have the opportunity
to submit written statements to the appeals
committee. The appeals committee will
establish a reasonable time for the submission
of such statements. Each party submitting a
written statement must provide a copy of the
statement to the other party.
• Examination by the appeals committee:
Throughout the hearing, the appeals committee
may question any witness who testifies.
The right to a hearing may be forfeited if the
practitioner fails, without good cause, to appear. In
the hearing the practitioner has the right to
representation by an attorney or other person of the
practitioner’s choice, to have a record made of the
proceedings, copies of which may be obtained by
the practitioner upon payment of any reasonable
charges associated in preparation thereof, to call,
examine, and cross-examine witnesses, to present
evidence determined to be relevant by the hearing
officer, regardless of its admissibility in a court of
law, and to submit a written statement at the closing
of the hearing. Upon completion of the hearing, the
practitioner involved has the right to receive a
written recommendation of the arbitrator, officer, or
panel, including a statement of the basis for the
recommendation, and to receive a written decision
of the health care entity, including a statement of
the basis for the decision.
The practitioner will be notified via certified letter
within five (5) days from the date of the hearing of
the final determination.
If a request for reconsideration or a formal hearing is
not made by the practitioner within thirty (30) days
of the receipt of the initial notification or fifteen (15)
days from the receipt of the notification of the Level I
appeal decision, BCBSNC will assume the provider
has forfeited their appeal rights and proceed with
the termination as stated in the initial notification
letter. A copy of the original notification will be sent
to Network Management operations to proceed
with termination from the network.
Communication will be sent from Network
Management operations to the credentialing
manager’s administrative assistant to confirm the
termination of the provider with copies sent to the
managers of credentialing, Network Management,
marketing, and customer service.
If a request is made by the practitioner, the
termination process will be suspended awaiting the
outcome of the reconsideration or formal hearing.
The practitioner may be reinstated if so indicated by
the outcome of the hearing. If the decision is
unchanged the Plan will proceed with termination.
If BCBSNC identifies quality concerns related to a
delegated practitioner, the complaint will be
forwarded to the delegated practitioner’s
credentialing department for follow up. Any actions
taken by the delegated practitioner as follow up
must be documented and a copy forwarded to
BCBSNC to be placed in the subscriber file.
Based on the credentialing committee
recommendation to decredential the practitioner,
a report is made to the appropriate licensing board.
The report details the disciplinary action taken
against the practitioner resulting in their loss of
privileges to participate in the BCBSNC managed
care network.
PAGE 19-4
Chapter 20
Marketing, advertising
and brand regulations
Chapter 20
Marketing, advertising and brand regulations
Marketing, advertising and brand regulations are the legal rules that must be followed when marketing or
advertising a Medicare plan offered by BCBSNC, or using the BCBSNC brand, and must be consistent with
applicable law and the terms of the participation agreement with BCBSNC.
20.1
Marketing and advertising
The marketing and advertising of Medicare Advantage health plans and Part D prescription drug plans by
health care providers is highly regulated by CMS and subject to tight restrictions. As a result, you cannot
conduct any marketing or advertising activity related to any Medicare plan offered by BCBSNC without prior
written approval from BCBSNC.
For more information regarding these restrictions, please refer to the Medicare Marketing Guidelines issued
by CMS and available through www.cms.gov.
20.2
Logo usage
Blue Medicare HMOSM and Blue Medicare PPOSM logos are available for use. Please do not alter any elements
within the logos.
20.3
Approvals
All marketing pieces (excluding general/operational business letters) that are being developed for dissemination
to the public must be reviewed and approved by BCBSNC or its designer prior to use.
All BCBSNC Medicare materials, after approval by advertising and brand marketing, must be submitted by
BCBSNC for review and/or approval by CMS, which carries up to a forty-five (45) day mandated allowable
approval time.
For questions, please contact your provider relations coordinator who can facilitate the process for you.
20.3.1 Sample Blue Medicare HMOSM and Blue Medicare PPOSM logos
PAGE 20-1
Chapter 21
Health Insurance
Portability and
Accountability Act
(HIPAA)
Chapter 21
Health Insurance and Portability Act (HIPAA)
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) calls for enhancements to
administrative processes that standardize and
simplify the administrative processes undertaken by
providers, clearinghouses, health plans, and
employer groups.
These common code sets enable a standard process
for electronic submission of claims by providers.
BCBSNC has adopted consistent standards, code
sets and identifiers for claims submitted electronically
and on paper. Code sets must be implemented by
the effective date to avoid claims denials.
Processes targeted for simplification include:
BCBSNC will maintain taxonomy or specialty codes
currently in use and will continue to assign these
codes for new providers. The codes are determined
during the credentialing and contracting process.
BCBSNC only accepts active codes from national
code set sources such as ICD-9, CPT, and HCPCS, as
part of our HIPAA compliance measures. As new
codes are released, please convert to them by their
effective date in order to prevent claims from being
mailed back for recoding or resubmission. Deleted
codes will not be accepted for dates of service after
the date the code becomes obsolete. Contact your
Network Management representative if you have
questions.
• Electronic transactions
• Code sets and identifiers
• Security
• Privacy
Please also reference the HIPAA companion guide
on the BCBSNC Web site at bcbsnc.com/content/
providers/blue-medicare-providers/
electroniccommerce/index.htm.
21.1
Electronic transactions
The administrative simplification provisions mandate
of HIPAA requires that all payers, providers, and
clearinghouses use specified standards when
exchanging data electronically. Providers and payers
must be able to send and receive transactions in the
designated EDI format. Providers will be able to
send and receive information from health plans and
payers, using the following standardized formats:
• Claims
• Claims status
• Remittance
• Eligibility
• Authorizations/referrals
21.2
Code sets and identifiers
Providers should use the following standardized
codes to submit claims to health plans:
• ICD-9 – CM
• CPT
Common identification numbers will be created for
providers, payers and employers, and will be
recognized by all entities when performing
electronic transactions. Standards for these unique
identifiers are currently under development.
21.3
Security
BCBSNC maintains a comprehensive security
program for safeguarding protected health
information in order to meet the requirements of
the HIPAA security rule and the North Carolina
Customer Information Safeguards Act. HIPAA
security requires a covered entity to provide
administrative, technical and physical safeguards
for protected health information maintained in
electronic form. The North Carolina Customer
Information Safeguards Act requires North Carolina
insurance companies to protect customer
information in all formats, whether electronic,
paper or oral.
• HCPCS
• CDT (were HCPCS dental codes, but now ADA
code, prefixed with “D”)
PAGE 21-1
Chapter 21
Health Insurance and Portability Act (HIPAA)
21.4
Privacy
Privacy regulations address the way in which a
health plan, provider or health care clearinghouse
may use and disclose individually identifiable health
information, including information that is received,
stored, processed or disclosed by any media,
including paper, electronic, fax or voice. Regulations
do allow for the sharing of information for
treatment, payment and health care operations,
including such plan-required functions as quality
assurance, utilization review or credentialing,
without patient consent. Limited sharing of
information may be allowed in instances where
national security may be impacted. Please read
BCBSNC notice of privacy practices for more
information about our privacy policies. Our notice
may be updated from time to time. Please visit our
Web site, bcbsnc.com, for the most current version.
21.5
Additional HIPAA information
• BCBSNC has adopted consistent standards, code
sets and identifiers for claims submitted
electronically and on paper.
• Additional HIPAA information is available through
the following organizations:
‡ Department of Health and Human Services at
www.hhs.gov
‡ North Carolina Healthcare and Information and
Communications Alliance at www.nchica.org
‡ Centers for Medicare and Medicaid Services at
www.cms.gov/hipaa or call 1-410-786-3000
PAGE 21-2
Chapter 22
Privacy and confidentiality
Chapter 22
Privacy and confidentiality
At Blue Cross and Blue Shield of North Carolina
(BCBSNC), we take very seriously our duty to
safeguard the privacy and security of our members
Protected Health Information (PHI), as we know you
do. In connection with recent developments
concerning the law of privacy and security of PHI,
including the HIPAA Privacy and Security Rules and
the North Carolina Customer Information
Safeguards Act, we have updated our corporate
privacy policies and procedures. The highlights of
these policies are described below. As contracting
providers, we want you to understand how we
protect our members’ information.
• We protect all personally identifiable
information we have about our members, and
disclose only the information that is legally
appropriate. Our members have the right to
expect that their PHI will be respected and
protected by BCBSNC.
• Our privacy and security policies are intended to
comply with current state and federal law, and
the accreditation standards of the national
committee for quality assurance. If these
requirements and standards change, we will
review and revise our policies, as appropriate.
We also may change our policies (as allowed by
law) as necessary to serve our members better.
• To make sure that our policies are effective, we
have designated a chief privacy official and a
privacy and security committee that are charged
with approving and reviewing BCBSNC’s privacy
and security policies and procedures. They are
responsible for the oversight, implementation
and monitoring of the policies.
22.1
Our fundamental principles for
protecting PHI
• We will protect the confidentiality and security of
PHI, in all formats, and will not disclose any PHI to
any external party except as we describe in our
privacy notice or as permitted or required by law
or regulation.
• Each of our employees receives training on our
policies and procedures and must sign a statement
when they begin work with us, acknowledging that
they will abide by our policies. Only employees
who have legitimate business needs to use
members’ PHI will have access to personal
information.
• When we use outside parties (business associates)
to perform work for us, as part of our insurance
business, we require them to sign an agreement,
stating that they will protect members’ PHI and will
only use it in connection with the work they are
doing for us.
• We communicate our practices to our members,
through our privacy notice, newsletter articles and
during the enrollment process they follow when
becoming a BCBSNC member.
• We will disclose and use PHI only where:
‡ required or permitted by law
‡ we obtain the member’s authorization
• We will respect and honor our members’ rights to
inspect and copy their PHI, request an amendment
or correction to their PHI, request a restriction on
use and disclosure of PHI, request confidential
communications, file a privacy complaint, request
an accounting of disclosures and request a copy of
our Notice of Privacy Practices.
Please read BCBSNC’s notice of privacy practices for
more information about our privacy policies. Our
notice may be updated from time to time. Please
visit our Web site, bcbsnc.com, for the most current
version.
PAGE 22-1
Chapter 22
Privacy and confidentiality
22.2
Privacy regarding services or items paid out-of-pocket
If a member pays the total cost of medical services and requests that a provider keep the information
confidential, the provider must abide by the member’s wishes and not submit a claim to BCBSNC for the
specific services covered by the member. Under current regulations, you may bill, charge, seek compensation
or remuneration or collection from the member for services or supplies that you provided to a member if the
member requests that you not disclose personal health information to us, and provided the member has
paid out-of-pocket in full for such services or supplies. Unless otherwise permitted by law or regulation, the
amount that you charge the member for services or supplies paid out-of-pocket, in full, may not exceed the
allowed amount for such service or supply. Additionally, you are not permitted to (i) submit claims related to,
or (ii) bill, charge, seek compensation or remuneration or reimbursement or collection from us for services or
supplies that you have provided to a member for which that member paid out-of-pocket.
PAGE 22-2
Chapter 23
Medicare Advantage and
Part D Compliance
Chapter 23
Medicare Advantage and Part D Compliance
23.1
Medicare Advantage and Part D Compliance for participating providers and
their business affiliates
Blue Cross and Blue Shield of North Carolina (BCBSNC) is required by the Centers for Medicare & Medicaid
Services (CMS) to maintain and administer a compliance program and a program to fight fraud, waste and
abuse (FWA). CMS advises that the seven (7) basic elements of the compliance program include:
• Maintaining written policies and standards of conduct
• Instituting high-level oversight, led by a compliance officer
• Providing effective training and education about Medicare program requirements
• Providing effective and accessible lines of communication between the compliance officer, employees,
and first tier, downstream, and related entities (FDRs)
• Ensuring that disciplinary standards are well-publicized
• Performing routine monitoring, auditing and identification of compliance risks
• Establishing procedures for prompt response to compliance issues.
BCBSNC ensures that these elements are met in the following ways:
• We provide our BCBSNC Code of Ethics and Business Conduct on our Web site at bcbsnc.com/content/
providers/blue-medicare-providers/index.htm, where we maintain an electronic library of policies,
including a written ethics and compliance program.
• BCBSNC has a compliance officer and a formal committee structure to provide oversight responsibilities
for compliance.
• BCBSNC provides annual training to its employees, its board of trustees, and sales agents on training
topics including: the BCBSNC Code of Conduct, Fraud, Waste and Abuse, and Medicare Compliance
(as stated in Chapter 9 of the CMS-issued Prescription Drug Benefit Manual and Chapter 21 of the
Medicare Managed Care Manual), providers, vendors, and other business partners who have met the
FWA training through enrollment in Part A or B of the Medicare program, or through accreditation as a
supplier of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies), are deemed to
have met the FWA training and education requirements for BCBSNC.
• BCBSNC offers several options for employees, producers and subcontractors to report issues or ask
questions, either directly or via anonymous hotlines, or related online reporting tools. If there is suspected
fraud, waste or abuse, please contact the Special Investigations Unit (SIU) at 1-800-324-4963. If there
are concerns about the actions of a BCBSNC employee, please contact the BCBSNC Ethics Hotline at
1-888-486-1554.
• Consequences for BCBSNC employees who violate the BCBSNC Code of Conduct or the FWA policy are
clearly communicated through our internal Code of Ethics and Business Conduct policy, and through
annual employee-required training courses.
• BCBSNC monitors hotline reports for trends, analyzes claims data to identify fraud, and reviews key CMS
compliance metrics. BCBSNC also performs risk assessments, executes audit plans, and conducts
subcontractor oversight.
• BCBSNC has written processes in place to investigate issues, track them to completion, and report
matters to government entities when necessary.
PAGE 23-1
Chapter 23
Medicare Advantage and Part D Compliance
Due to BCBSNC’s relationship with CMS, Blue MedicareSM – participating providers should be aware of several
key federal rules:
• Anti-Kickback Statute – This statute imposes criminal penalties for individuals or entities who knowingly
and willfully offer, pay, solicit, or receive remuneration to induce or reward business reimbursement in
federal health care programs.
• False Claims Act – This act imposes liability on any person of an organization who submits a claim to the
federal government that is known or should be known to be false.
• Excluded Entity Provision of Social Security Act – Medicare Part C and Part D contractors are prohibited
from employing or contracting with an individual or entity who is excluded from participation in federal
health care programs.
PAGE 23-2
Chapter 24
Forms
Chapter 24
Forms
The following forms are referenced in the preceding sections of this guide. We have included copies of the
following forms for you to copy and use at your convenience.
• Medicare Advantage – Power Operated Vehicle (POV)/Motorized Wheelchair Request Form
• Provider Inquiry Form
• Level I Provider Appeal Form for Blue Medicare HMOSM and Blue Medicare PPOSM
Note: Pharmacy forms, including drug-specific fax forms, are available for download via our Web site or by
contacting the Provider Line at 1-888-296-9790. Some forms are updated at least once annually. Always
verify you are using the most current version by visiting us on the web at bcbsnc.com/content/medicare/
member/policies/approval.htm.
PAGE 24-1
Chapter 24
Forms
Sample Medicare Advantage – Power Operated Vehicle (POV)/Motorized Wheelchair Request
Medicare Advantage – Power Operated Vehicle (POV)/Motorized Wheelchair Request Form
Patient Name:
Patient ID# and Date of Birth:
Physician Name:
Physician Phone Number:
DME Item Requested (check only one box):
POV/Scooter
Motorized Wheelchair
Patient’s Medical Diagnosis(es):
Please answer the questions below. Submit this form and all medical records to support your answers and the medical necessity of the
requested equipment. The medical notes must be submitted with this request.
1. Does the patient have a mobility limitation that significantly impairs his/her ability to participate in one or more mobilityrelated activities of a daily living (MRADLs) in the home?
Yes
No
Yes
No
3. Can the patient’s mobility needs in the home be sufficiently resolved with the use of a cane or walker?
Yes
No
4. Can the patient’s mobility needs in the home be sufficiently resolved with the use of a manual wheelchair?
Yes
No
5. Does the patient’s typical environment support the use of wheelchairs including scooters/POVs?
Yes
No
6. Does the patient have sufficient upper extremity function to propel a manual wheelchair in the home to
participate in MRADLs during a typical day?
Yes
No
7. Does the patient have sufficient strength and postural stability to operate a POV/scooter?
Yes
No
8. If a power wheelchair is being requested, are the features requested needed to allow the patient to participate in
one or more MRADLs?
Yes
No
If yes, please describe the specific mobility limitation and quantify the degree of impairment.
2. Does the patient have other conditions that limit the patient’s ability to participate in MRADLs at home?
If yes, what are the conditions?
I certify that, to the best of my knowledge, my answers to the above questions are accurate and supported by the
attached medical records.
Physician Signature:
Please return completed form to case management:
Fax Number:
1.336.659.2945 or
Address:
Blue Cross and Blue Shield of North Carolina
Attention: Care Management & Operations
PO Box 17509
Winston-Salem, NC 27116-7509
10/26/2005
PAGE 24-2
Chapter 24
Forms
Sample Provider Inquiry Form
Provider Inquiry Form
Please let us know whenever you have a problem or a question. Complete all sections if your inquiry concerns a specific
patient. If it is a general inquiry, complete the applicable sections. Please fax to the following number 1-336-659-2962.
Please print or type:
Provider’s last name
First name
Practice name
Provider number
Office address (number, street, suite number)
City, State, ZIP
Phone number
Fax number
Patient’s last name
First name
Member ID number
Date of service
Date of inquiry
Contact name for follow-up
Nature of inquiry
(please check the
box that applies
and comment):
Claim status
Questioning
reimbursement
Requested
information attached
Other: please explain
Reason for denial
Provider’s comments:
Status of claim
Claim paid on:
Check number:
Amount:
Claim is pending for:
No record of claim receipt:
Claim denied due to:
Claim in process:
Other:
PAGE 24-3
Chapter 24
Forms
SM
SM
Sample Level I Provider Appeal Form for Blue Medicare HMO and Blue Medicare PPO
Level I Provider Appeal Form for
Blue Medicare HMO and Blue Medicare PPO
SM
SM
Blue Cross and Blue Shield of North Carolina is an independent
licensee of the Blue Cross and Blue Shield Association.
Section I: Patient information
Alpha prefix (Copy from the member’s BCBSNC identification card)
Patient date of birth
-
-
Subscriber number (Copy from the member’s BCBSNC identification card)
Patient name (First, middle initial, last)
Section II: Physician information
Requesting physician (Print first, last name)
-
Fax
Requesting physician’s signature (Signature and date)
-
-
Phone
-
Physician NPI number
Physician mailing address (Street or P.O. Box, City, State & Zip Code)
Section III: Appeal information
Date of service
-
Date of notification of payment
-
-
CPT codes
-
Diagnosis codes
.
.
Claim identification number
MEDICAL NECESSITY:
Cosmetic
Experimental/Investigational
No authorization for inpatient admission
Not medically necessary
BILLING/CODING:
OTHER:
Non-Contracting Provider Payment Disputes
Coding/Bundling or Fee Denials
Global Period Denial
Re-bundling
Services Not Eligible for Separate Reimbursement
FAX NUMBER FOR POST SERVICE APPEALS – (919) 287-8815
Note: All other requests should be submitted using the Provider Inquiry Form in the Blue Medicare HMO and Blue Medicare PPO
Provider Manual.
Comments (If additional space is needed, please use the back of this form)
SM
SM
Records attached
This form is intended for use only when requesting a review for post service appeal requests for Medicare Advantage membership. Completed forms accompanied by any
supporting documentation should be sent to: Provider Appeals Unit, Blue Medicare HMOSM and Blue Medicare PPO,SM PO Box 17509, Winston-Salem, NC 27116-7509 or
Fax: (919) 287-8815.
Please refer to the Blue Medicare HMOSM and Blue Medicare PPOSM provider manual located on the BCBSNC Web site for providers at bcbsnc.com/content/providers/bluemedicare-providers/resources-and-forms/index.htm or contact Network Management for assistance with the claims inquiry process.
PAGE 24-4
Chapter 25
Glossary of terms
Chapter 25
Glossary of terms
Additional benefits – Health care services not
CMS – Refers to the center for Medicare and
covered by Medicare.
Medicaid services. It is the agency responsible for
administering Medicare and federal participation in
Medicaid. It also oversees the provision of health
care benefits to Medicare beneficiaries by CMSapproved Medicare Advantage organizations.
Agreement – The agreement between BCBSNC and
members that includes certificate of coverage,
riders, amendments and attachments.
Annual Election Period (AEP), enrollment period –
The AEP is the period of October 15 through
December 7 during which Medicare beneficiaries
may elect enrollment in an MA Plan for the following
year. This period will also be the period during
which an enrollee in an MA Plan may elect to return
to original Medicare or elect a different MA Plan. In
addition to the AEP, BCBSNC will accept
applications during a continuous enrollment period
each month for new Medicare beneficiaries and
those with eligibility for a Special Election Period
unless it provides notice to CMS and the public that
it has changed its continuous open enrollment policy.
Basic benefits – All health care services that are
covered under the Medicare Part A and Part B
programs (except hospice services), and additional
services that we use Medicare funds to cover.
Benefit period – A “spell of illness” is a period of
consecutive days that begins with the first day (not
included in a previous spell of illness) on which a
patient is furnished inpatient hospital or extended
care services and the spell of illness ends with the
close of a period of sixty (60) consecutive days
during which the patient was neither an inpatient of
a hospital nor an inpatient of a skilled nursing
facility. To determine the sixty (60) consecutive day
period, begin counting with the day on which the
individual was discharged. Spell of illness also
applies to home health.
Calendar year – A twelve (12) month period that
begins on January 1 and ends twelve (12)
consecutive months later on December 31.
Certificate of Coverage (COC) – The document
which describes services and supplies provided to a
member. Same as evidence of coverage.
Center for Health Dispute Resolution (CHDR) – An
independent CMS contractor that reviews appeals
by members of Medicare managed care plans, including
Blue Medicare HMOSM and Blue Medicare PPOSM.
Coinsurance – A fixed percentage of the recognized
charges for a covered service that a member is
required to pay to a provider.
Coordination of Benefits (COB) – Means those
provisions, which BCBSNC uses to coordinate
benefits for costs incurred due to an incident of
sickness or accident, which may also be covered by
another insurer, group service plan or group health
care plan. These provisions are also known as
Medicare Secondary Payer (MSP).
Copayment – Means a fixed dollar amount of
payment made by a member to a provider.
Copayments must be made at the time services
and/or supplies are received. The schedule of
copayments can be found in Attachment A of the
certificate of coverage.
Custodial care – Care furnished for the purpose of
meeting non-medically necessary personal needs
which could be provided by persons without
professional skills or training, such as assistance in
mobility, dressing, bathing, eating, preparation of
special diets and taking medication. Custodial care
is not covered by BCBSNC or Original Medicare
unless provided in conjunction with BCBSNC
approved skilled nursing care.
Designated provider/authorized provider – Refers to
the provider appointed by BCBSNC to provide a
specific covered service.
Disenrollment – Means the process of ending or
terminating membership in BCBSNC.
Drugs – Defined as inpatient medications which
require a physician’s order or outpatient medications
which require a prescription. To be covered, a drug
must be covered by Medicare and BCBSNC using
Medicare coverage guidelines.
PAGE 25-1
Chapter 25
Glossary of terms
Durable Medical Equipment (DME) – Means
Grievance and appeal procedure – The method of
equipment which is: (a) designed and intended for
repeated use; and/or (b) primarily and customarily
used to serve a medical purpose; and (c) generally
not useful to a person in the absence of disease or
injury; and (d) appropriate for use in the home. Must
meet Medicare guidelines for coverage. Braces and
prosthetic devices as defined by Medicare are
considered part of the DME benefit.
resolving member complaints, grievances and appeals.
Emergency medical condition – A medical condition
manifesting itself by acute symptoms of sufficient
severity, including but not limited to severe pain, or
by acute symptoms developing from a chronic
medical condition that would lead a prudent
layperson, possessing an average knowledge of
health and medicine, to reasonably expect the
absence of immediate medical attention to result in
placing the health of an individual or unborn child in
serious jeopardy, serious impairment to bodily
functions or serious dysfunction of a bodily organ
or part.
Home health services – Shall mean skilled nursing
care or therapeutic services provided by an agency
or organization licensed by the state and operating
within the scope of its license. For home health
services to be a covered benefit, the member must
be homebound (confined to home), under a plan of
treatment established and periodically reviewed and
approved by a physician, and in need of intermittent
skilled nursing services, physical therapy or speech
therapy. (Please note: custodial care is not included
under this definition.)
Hospice – An organization or agency, certified by
Medicare, that is primarily engaged in providing
pain relief, symptom management and supportive
services to terminally ill people and their families.
Indemnification, beneficiary financial protection –
Ensures that the member can not be held financially
liable for payment of fees which are the legal
responsibility of BCBSNC. This would include the
services of BCBSNC contracting providers as well as
non-contracting providers.
Emergency services – Covered inpatient or
outpatient services that are (1) furnished by a
provider qualified to furnish emergency services;
and (2) needed to evaluate or stabilize an
emergency medical condition.
Lifetime – Means any period of time throughout the
member’s life when member is covered by BCBSNC.
Evidence of coverage – Shall have the same meaning
“Lock in” – Means, as a member, all of your necessary
as certificate of coverage and refers to this
document, which explains covered services and
defines our obligations and your rights and
responsibilities as a member of BCBSNC.
health care treatment and services (other than
emergency medical condition, urgently needed
services, out of area renal dialysis and required poststabilization care), must be provided by a contracting
provider, or authorized by BCBSNC.
Exclusions – Items/services, which are not covered
under this certificate of coverage.
MA – Refers to the term, Medicare Advantage
Experimental and/or investigational – Refers to
organization, formerly Medicare+Choice. Provisions
of the program are defined under Medicare Part C.
medical, surgical, psychiatric and other health care
services, supplies, treatments, procedures, drug
therapies or devices that are determined by
BCBSNC to be either: (a) not generally accepted or
endorsed by health care professionals in the general
medical community as safe and effective in treating
the condition, illness or diagnosis for which their use
is proposed, or (b) not proven by scientific evidence
to be safe and effective in treating the condition,
illness or diagnosis for which their use is proposed.
Medically necessary – Refers to the medical need
for diagnosis and care of treatment of a member.
Medically necessary supplies and services are
supplies and services that are: (a) provided for the
diagnosis, treatment, cure or relief of a condition,
illness, injury or disease and not for experimental,
investigational or cosmetic purposes; (b) necessary
for and appropriate to the diagnosis, treatment,
cure or relief of a health condition, illness, injury,
disease or its symptoms;
PAGE 25-2
Chapter 25
Glossary of terms
(c) within generally accepted standards of medical
care in the community; and (d) not solely for the
convenience of the member, member’s family or the
provider. Plan may compare the cost-effectiveness
of the alternative services or supplies when
determining which of the services or supplies will be
covered. BCBSNC shall have the full power and
discretionary authority to determine whether any
care, service or treatment is medically necessary,
subject only to a member’s right of grievance and
appeal defined in the certificate of coverage, and
BCBSNC may compare the cost-effectiveness of
alternative services or supplies when determining
which of the services or supplies will be covered.
Medicare Part A – Hospital insurance benefits
including inpatient hospital care, skilled nursing
facility care, home health agency care and hospice
care offered through Medicare.
Medicare Part B – Supplementary medical insurance
that is optional and requires a monthly premium.
This a called the Medicare Part B premium. Part B
covers physician services (in both hospital and
non-hospital settings) and services furnished by
certain non-physician practitioners. Other Part B
services include lab testing, durable medical
equipment, diagnostic tests, ambulance services,
prescription drugs that cannot be self-administered,
certain self-administered anti-cancer drugs, some
other therapy services, certain other health services
and blood not covered under Part A.
Medicare Part C – A federal program with a primary
goal of providing Medicare beneficiaries with a
range of health plan choices through which to
obtain their Medicare benefits. CMS contracts with
private organizations offering a variety of private
health plan options for Medicare beneficiaries,
including both traditional managed care plans, such
as HMOs, and new options that were not previously
authorized. Originally known as the Medicare+Choice
program, it was renamed by CMS and is now known
as the Medicare Advantage program.
Medicare Part D – Effective January 1, 2006, this is a
new federal program offering prescription drug
benefits to Medicare beneficiaries. This benefit can
be offered by private organizations including
pharmacies and private health plans.
Medicare, Original Medicare – The federal
government health insurance program established
by Title XVIII of the Social Security Act.
Medicare Advantage organization – A public or
private entity organized and licensed by the State as
a risk-bearing entity that is certified by CMS as
meeting MA requirements. MA organizations can
offer one (1) or more MA Plans. BCBSNC is a
Medicare Advantage organization.
There are three (3) types of M+COs, (1) coordinated
care plans, like BCBSNC, which include a network of
providers that are under contract or arrangement
with the MA to deliver the services approved by
CMS, (2) Medicare Advantage Medical Savings
Accounts (MSA) and (3) Medicare Advantage private
fee-for-service plans.
Member – Refers to the Medicare beneficiary,
entitled to receive health care services under the
terms of this BCBSNC certificate of coverage, who
has voluntarily elected to enroll and whose
enrollment in the BCBSNC Medicare Advantage
Plan has been confirmed by CMS.
National coverage decisions – Refer to coverage
issues mandated by Medicare.
Non-contracting medical provider or facility – Any
professional person, organization, health facility,
hospital or other person or institution licensed
and/or certified by the state or Medicare to deliver
or furnish health care services; and who is neither
employed, owned, operated by nor under contract
with BCBSNC to deliver covered services. (These
providers differ from contracting providers who
affiliate with BCBSNC to provide care for Plan
members.)
Noncovered services – Those medical services and
supplies described in the member’s certificate of
coverage as not covered by BCBSNC.
PAGE 25-3
Chapter 25
Glossary of terms
Optional supplemental benefits – Those benefits not
covered by Medicare which are purchased for an
additional Plan premium at the option of the
Medicare beneficiary. The existence or availability of
optional supplemental benefits may vary by county.
BCBSNC does not offer any optional supplemental
benefits.
Out-of-area service – Refers to those services and
supplies provided outside the Blue Medicare HMOSM
or Blue Medicare PPOSM service area.
Post-service appeal – Shall have the meaning
assigned to that term in Section 7.11(c)(ii)(A) of the
Thomas/Love Settlement Agreement.
Post-stabilization care – Covered services, related to
an emergency medical condition, that are provided
after an enrollee is stabilized in order to maintain
the stabilized condition, or to improve or resolve the
enrollee’s condition, as specified by CMS.
Primary Care Physician (PCP) – A contracting
physician selected by a BCBSNC member and is
responsible for providing or arranging for medical
and hospital services covered under this certificate
of coverage. Note: A person who has acquired the
requisite qualifications for licensure and is licensed
in the practice of medicine.
Prior authorization – A system whereby a provider
the complexity; degree of skill needed; type or
specialty of the provider; range of services provided
by a facility and the prevailing charge in other areas.
Service area – The geographic area approved by
CMS within which an eligible Medicare beneficiary
may enroll in a particular Medicare Advantage Plan
offered by BCBSNC. A listing of the approved service
area can be found in Chapter 4 of this manual.
Skilled nursing facility – A facility certified by
Medicare which provides inpatient skilled nursing
care, rehabilitation services or other related health
services. The term skilled nursing facility does not
include a convalescent nursing home, rest facility or
facility for the aged which furnishes primarily custodial
care, including training in routines of daily living.
Spell of illness – See benefit period.
Supplemental benefits – Those benefits not covered
by Medicare for which the MA organization may
charge the enrollee an additional Plan premium.
These benefits are offered as an option for the
Medicare enrollee to select (optional supplemental
benefits) or as a requirement for enrollment
(mandatory supplemental benefits). BCBSNC does
not offer any optional supplement benefits.
Termination date – The date that coverage no
must receive approval from BCBSNC before the
member is eligible to receive coverage for certain
health care services.
longer is effective, (i.e., at 12:00 midnight on the
last day coverage is effective). Also referred to as
disenrollment date. Coverage typically ends on the
last day of the month.
Quality Improvement Organization (QIO) – An
Urgent care facility – A health care facility whose
independent contractor paid by CMS to review
medical necessity, appropriateness and quality of
medical care and services provided to Medicare
beneficiaries. Upon request, the QIO also reviews
hospital discharges for appropriateness and quality
of care complaints.
Recognized charge(s) – Means the charge for a
covered service which is the lower of (a) the
provider’s usual charge for furnishing it; or (b) the
charge BCBSNC determines to be the recognized
charge made for that service or supply. In determining
the recognized charge for a service or supply that is
unusual, not often provided in the area, or provided
by only a small number of providers in the area,
BCBSNC may take into account factors such as:
primary purpose is the provision of immediate,
short-term medical care for non-life-threatening
urgently needed services.
Urgently needed services – Means covered services,
that are not emergency services, provided when you
are temporarily absent from the BCBSNC service
area (or, under unusual and extraordinary
circumstances, provided when you are in the service
area but your PCP is temporarily unavailable or
inaccessible) when such services are medically
necessary and immediately required (1) as a result of
an unforeseen illness, injury or condition, and (2) it is
not reasonable given the circumstances to obtain
the services through your PCP.
PAGE 25-4
Blue Medicare HMOSM and Blue Medicare PPOSM Supplemental Guide
The Blue Book
SM
Provider eManual
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