Frequently Asked Questions (FAQs)
Here you can find some questions we've received from the provider community about these topics. If you have a question you would like to submit please contact us.
- Where can I find a copy of BlueChoice HealthPlan's bundling guidelines? From the Medical Policies and Clinical Guidelines page on our website you can review CAM 138 Corporate Administrative/Medical Policy Guidelines (Medical Necessity, Investigational/Experimental) for our bundling guidelines. You can also get this information from the member’s specific benefit plan. It is important to note that a claim has to be processed before it can be determined which codes will bundle.
- Will BlueChoice® accept the new X modifiers? Yes, BlueChoice accepts the new modifiers – XE, XP, XS and XU – the Centers for Medicare and Medicaid Services (CMS) mandated for use beginning January 1, 2015. CMS established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, used to define a “Distinct Procedural Service.”
- Is 24/7 provider access required for all lines of business? Only BlueChoice primary care providers are contractually required to have physician accessibility 24 hours a day, seven days a week.
- Can I submit the referring provider national provider identifier (NPI) if I do not have the rendering provider’s NPI? No. A provider advocate will contact providers that submit claims without the rendering information. The lack of rendering provider information will cause claim denials.
- How can I receive your monthly provider newsletter? You can visit the Provider News page on our website to read the latest edition of BlueNewsSM for Providers and other publications. To have the newsletter sent to you via direct mail or email please contact Provider Education by emailing email@example.com.
- Are there specific guidelines for pre-admission testing (ex: EKG) when performed in physician’s office? If you perform pre-admission testing, such as an EKG in the physician’s office, then you should file it like any other procedure through an office visit. If the place of service is at the office, then you bill as an office claim. When you do the pre-admission testing at the hospital within 72 hours of admission, then you should bill it on the UB with the occurrence code 42.
- Will you deny claims for “medical records not received in a timely manner” if you receive records after 10 calendar days? You should submit medical records immediately once you receive the request. If not, this will prolong any possible payment. The request may include a date range to return the medical records. Typically, we respond to medical records requests within seven to 14 days but no more than 30 days.
- Why are copays doubled when our physician assistant sees a patient? We determine the copayment amount by the rendering physician specialty code and the member’s specific benefit plan.
- How do I identify a BlueChoice member? Ask your patient for his or her current member ID card at each visit. Photocopy the front and back of the card regularly. Having the current card will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delays.
- What should I collect from a BlueChoice member? Ask your patient for his or her current member ID card at each visit. Photocopy the front and back of the card regularly. Having the current card will enable you to submit claims with the appropriate member information (including alpha prefix) and avoid unnecessary claim payment delays.
- How do I file Medicare Crossover claims? File the claim to your Medicare carrier for primary payment. BlueChoice will not receive claim information for the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. GHI (the CMS vendor) normally will electronically forward Medicare secondary claims directly to the member’s supplement plan. Check the Medicare Remittance Notice to make sure GHI forwarded the claim. If it did, you do not need to take further action. The paper remittance notice will state "Claim information forwarded to: [Name of secondary payer]." The 835 (electronic remittance) record can also carry the secondary forwarding information. BlueChoice will send you your payment or processing information after it receives the Medicare payment. Please allow 45 days from the primary payment date for the processing of the secondary claim. If the claim did not cross over electronically to the supplement plan, you can file the secondary claim to BlueChoice electronically using My Insurance ManagerSM.
- Should I resubmit a claim if I do not receive payment? No. If you have not received payment for a claim, do not resubmit the claim. We will deny it as a duplicate. This also causes member confusion because of multiple Explanations of Benefits (EOBs). You should always check claim status through My Insurance Manager. In some cases, a claim may pend because medical review or additional information is necessary. We will contact you when we need additional information in order to finalize the claim.
- When should I contact my provider advocate? If you have a training request or question that is not related to specific claim disposition or member information, please contact your provider advocate.
- Does BlueChoice require prior authorization? BlueChoice requests notification for any admission to a hospital or skilled nursing facility. This notification enables the member to access optional benefits, such as case management and disease management programs, along with discharge planning. Other services may also require prior authorization. You can get prior authorization using the Authorization/Precertification/Referral link in My Insurance Manager. You can submit prior authorization requests for BlueChoice. This feature also includes the referral and authorization status functions. Note: Prior authorizations do not guarantee payment of benefits. Claim payments are subject to the rules of the plan.
- BlueChoice continues to ask for medical records and consent forms. We are an ancillary service provider, and do not know or see a patient until we administer anesthesia in the operating/procedure room. Why can’t BlueChoice pay our claims and withhold payment from the surgeon who has the medical records? Please continue to return the medical records requests to us with the referring/rendering providers’ names included. We cannot withhold payment from the surgeon because these are not global charges. We need the medical records to reimburse any professional provider in this situation.
- Where do I submit the claim if I am using home as the place of service and there are several out-of-state addresses shown? Wherever the member receives the item is where you should bill it. For example, if a patient is visiting South Carolina then you should bill to BlueChoice HealthPlan of South Carolina. When filing claims, the place of service is 12 for home and 99 for other. For more information please see our provider news bulletin Ancillary Provider Reminders on our website. We receive blood samples from all over the country.
- Can we file to a BlueChoice plan in another state? Yes, you can file to another Blue Plan. A laboratory provider can file claims where the specimen was collected or where the referring physician is located.
- Should we notify members you will bill them if they visit an out-of-network lab? Yes, we require you to inform members we may bill them for for use of a non-participating lab.
- Should providers file lab claims to Host or Home Plan? A laboratory provider can file claims where the specimen was collected or where the referring physician is located.
- How can providers get claim status and/or the first processed EOBs without contacting the Home Plan? You can get claim status using My Insurance Manager available on our website. Providers should check the claims’ status prior to refiling any claims. Refiling claims within 30 days of the previously filed claim may not allow the Home Plan enough time to process the initial claim and can cause further delays.
- Our health care system has several locations that use the same TIN when submitting claims. How do we get our claims to process under the correct NPI and not under the TIN so you send payments to the accurate location? When filing your claims you should use the NPI for the location where the services are rendered.
- How can the Blue Plans’ communication with providers be improved? Blue Plans, including BlueChoice HealthPlan of South Carolina, are constantly developing ways to service members and providers in a timely manner. You can use our electronic services for fast and easy access to verifying eligibility, getting precertification, verifying claim status, claims submission and more. Provider Services representatives are only available for those inquiries that cannot be answered by querying the VRU or utilizing our self-service Web portal.
- Why can’t I view group numbers, deductible and out-of-pocket information for other plans when using My Insurance Manager to verify eligibility? The member’s Home Plan holds the patient’s membership and benefits information. My Insurance Manager is a Web tool specific to BlueChoice HealthPlan of South Carolina. It does provide general eligibility and benefits information for other Blue Plan members. The information we receive for members from other plans may not contain all of the information you are accustomed to seeing when viewing a South Carolina member in My Insurance Manager. If there is additional information you need regarding the member’s benefits you should contact the member’s Home Plan.
- How does the provider financial responsibility requirement impact providers? You will be responsible for getting prior authorization for inpatient facility services for out-of-area members. The member will not be responsible when prior authorization is required but not received for inpatient services. BlueCard® members will now be treated the same as local BlueChoice Plan members. Failure to get necessary prior authorizations will result in claim penalties or denials.
- Is the Return Coverage Page form for medical records available on the website? No, the Return Coverage Page is not yet available on our website. It is included as the fourth page of a medical record request you may receive from BlueChoice HealthPlan of South Carolina.
- If records are requested via a response from My Insurance Manager is there a specific form for providers to submit medical records? Complete a Medical Review Form, found on our website in the Forms section. Attach the applicable medical records and supporting information to the form. Fax or mail the form and supporting documents to the appropriate service area.
- When are providers supposed to receive medical record requests? Providers may receive requests for medical records as needed for claims related purposes and non-claims related matters that support our quality programs.
- Why does it take so long to submit claims from Host to Home Plan? BlueChoice applies pricing according to the provider’s contract and electronically forwards the claim to the member’s Home Plan. The Home Plan processes according to the member’s benefits and transmits data back to BlueChoice. This generally takes 30 days.
Electronic Data Interchange (EDI) FAQs
- What can I do about an issue with electronic claims and modifiers not transmitting through our clearinghouse? Our EDI department can work with your clearinghouse if there is a problem with us not getting your claims submissions. Contact EDI by email at firstname.lastname@example.org or by phone at 800-868-2505.
- Where and how do I submit claims? You should always submit claims electronically to BlueChoice HealthPlan of South Carolina. Be sure to include the member’s complete identification number when you submit the claim. The complete identification number includes the three-character alpha prefix (with the exception of the Federal Employee Program). Do not make up alpha prefixes. Submitting claims with incorrect or missing alpha prefixes and member identification numbers can result in processing delays, as well as claim denials. For prompt payment, we encourage electronic claims submission. Transmit claims in the HIPAA 837 format under the appropriate carrier codes. You should complete all applicable claim information in full to ensure you receive accurate payment without delay. You can also file both professional and institutional claims (primary, secondary and corrected claims) in My Insurance Manager.
Federal Employee Program (FEP) FAQs
- Will you cover the shingles vaccine as a preventive service in 2015? The member’s plan determines if we will cover the shingles vaccine as preventive service. Please verify benefits via My Insurance Manager. In 2015, the FEP will cover the cost for the shingles vaccination.
- When will providers be able to check FEP eligibility via My Insurance Manager? In May 2015, providers will be able to access eligibility and claim status for FEP members via My Insurance Manager. We will give you more information about this new enhancement soon.
- Do you cover V-codes for genetic counseling? Yes, but the member must meet certain requirements. Please contact your provider advocate for further information.
- How can I determine if a patient has the FEP Standard Option plan or the FEP Basic Option plan? You should check the member’s ID card. The plan name appears on the front of the ID card in the upper right corner. You may also find our member identification card guide helpful. Review What You Need to Know About Member Identification Cards.
Health Insurance Marketplace (Exchange) FAQs
- Why is BlueChoice not offering my patient's plan for 2017? Medical costs for people in ACA plans offered on the federal exchange are much higher, because these members tend to be sicker and require medical care more often. Those high costs are why other insurance companies have left the market. As these companies drop their plans, their members have turned to BlueCross and BlueChoice. In order for us to stay in the market, we needed to find ways to streamline our operations and cut out any duplication. The best way for us to do that is by rolling BlueChoice members who have a Blue Option exchange plan over to BlueCross. While this change may seem big, it really has a small impact on our members. BlueCross plans are very similar to BlueChoice plans and use the same provider network.
- When does this change take effect? The current Blue Option coverage stays in effect, as long as your patients pay their plan premiums, until the end of the year (Dec. 31, 2016). Members can keep using their Blue Option ID card until then. They will receive a new ID card from BlueCross to use starting January 1, 2017.
- Will premiums go up under a new BlueCross plan? Many members with ACA plans will see their premium rates increase for 2017 because customers in this market are sicker and use more services. This is the reason that many insurance companies have left the market. Companies like BlueCross that are staying in the market must raise premiums to keep up with these rising costs. If members are receiving tax credits (subsidy) for a plan purchased on the exchange, the impact of a premium rate increase may be minimal because the amount of subsidy the member may qualify for in 2017 will be adjusted as well. If a member is not receiving tax credits (subsidy), he or she may want to check to see if they qualify for 2017. It’s always a good idea to do this just in case something has changed that could now make an individual eligible for this extra financial help.
- When will members find out what their 2017 premium will be? Members should receive a letter in early October that shows the BlueCross plan that is the most like the Blue Option plan they have today with BlueChoice. If members want to keep this plan for their 2017 coverage, all they need to do is to update their application with the Health Insurance Marketplace and select that plan. If members want to shop around and see other plans that might better fit their needs for 2017, they still have the option to do so. The Open Enrollment Period starts Nov. 1. Just be sure to select a plan by Dec. 15 to have your coverage take effect Jan. 1, 2017.
- How did you decide what BlueCross plan is closest to a member's current Blue Option plan? We mapped plans using out-of-pocket costs for core plan benefits, such as your deductible, copayments for primary care and specialty doctors’ office visits, pharmacy benefits and cost, and total out-of-pocket amounts.
- Will benefits be different under a BlueCross plan? Under the law, all qualified health plans must offer the same set of essential health benefits. However, members may see some differences in pharmacy, dental or vision coverage, or added-value programs and services.
- When and where can I see all of the BlueCross plans being offered for 2017? You can view all plans for 2017 by going to BlueCross’ website at www.SouthCarolinaBlues.com starting on Nov. 1, 2016. If a member is eligible for financial help (tax credits/subsidy), or think he or she might be, they should go to the Health Insurance Marketplace at www.HealthCare.gov. Members will also be able to enroll in a plan for 2017 starting Nov. 1, 2016.
- Can members keep the doctor they have now or will they have to change? The EPO network that BlueCross uses for its ACA individual plans has the same South Carolina providers as the EPO network that BlueChoice uses for the member's current Blue Option plan. The member will not have to switch doctors.
- My patient is in the middle of being treated for an illness/pregnancy. Will this change affect their benefits or treatment plan? BlueChoice and BlueCross ACA plans contain the same essential health benefits, so BlueCross will cover these services. Their out-of-pocket costs may be a little different, depending on the BlueCross plan selected. If there is an authorization for a medical service or maternity care under the member's Blue Option plan, we will transfer that authorization to their new BlueCross BlueEssentials plan. When that occurs, you and your patient will get a new authorization letter. You can also use our website to verify authorization status.
- Will members need a new prescription from their doctor once coverage changes from BlueChoice to BlueCross? If members have refills left on their original prescriptions, they will be able to refill them. After that, your patients will need a new prescription. Keep in mind that pharmacy benefits and out-of-pocket costs may be a little different under their new BlueCross plan. So members may pay a different amount at the drug store once their BlueCross coverage begins. Some specialty drugs may require pre-authorization. BlueCross will automatically re-authorize some medications for chronic conditions, but others used for more complex illnesses may need to be re-authorized. If this is the case, we will notify you and your patient. If the drug is approved under their new BlueEssentials plan, we will send a new authorization letter to you and the member.
- Is it the provider’s choice to participate in an Exchange plan? Yes, but we have to invite you into the network. Contact your provider contract manager for additional information on network participation.
- Why did My Choice AdvantageSM change its name to Blue OptionSM? We made the name change to distinguish the BlueChoice HealthPlan commercial plans from the Exchange products.
- If I am affiliated with a hospital that has not joined the Exchange network, can I see an individual Exchange member? No, you will not be able to see this member.
- Are pediatric or adult dental benefits available for Exchange plans? Certain Blue Option plans do offer dental services for children and adults.
- Should I use the Transition of Care form for emergencies? It is not necessary to submit a Transition of Care form for emergency coverage. Use it when a member is under the care of a physician who is not in our Exchange networks. Our utilization management area will review each case and may approve continued care with the out-of-network provider for a specified time.
- If our physicians are credentialed with BlueCross® BlueShield® of South Carolina Exchange plans are they also credentialed for the BlueChoice Exchange plans? The BlueChoice Exchange plan requires individual provider credentialing. You are not automatically enrolled in BlueChoice as a result of your participation with BlueCross.
- What are the timely filing guidelines? You have 12 months from the date of service to file claims for patients in Blue Option. You have 90 days to file corrected claims and 60 days to submit appropriate documentation for medical reconsideration.
- Why is the letter B beside the PPO suitcase on the member’s ID card? The suitcase on the front of the card, lower right, indicates the network members access when out of state. The letter B beside the PPO suitcase stands for Basic. This means the member belongs to the public federal Exchange. All members may not have the letter B on their ID cards, but the plan name will always let you know if a member belongs to an Exchange plan. All group products continue to access the broad commercial networks. This includes those purchased through the federal or private Exchange.
- Can we bill patients if they become delinquent in paying their premiums? How will we know? My Insurance Manager and your remit will alert you if a member is delinquent in paying premiums. If the member does not receive a premium subsidy, then you can proceed as you do for commercial plans today. If the member receives a premium subsidy, claims will process during the first 30 days of delinquency and will pend for the next 60 days of delinquency. After 90 days of delinquency, we will disenroll members from Blue Option.
- If the patient never pays, will BlueChoice recoup claims paid during the first month? The grace period does not apply to Exchange members who do not receive a subsidy. If those members are delinquent, those claims will pend immediately upon delinquency, just as with the commercial products today. If the enrolled member never makes a premium payment, then we will deny claims, just as we do today with our commercial business. There will be no claims processed for us to recoup.
- What do you consider a "true emergency"? We determine the classification of an emergency by the diagnosis code you file on the patient’s claim.
- What if there is not a particular specialty listed as in network? If a specialist is not in the Blue Option network, then a member can see that specialist by completing a Transition of Care Request form. You can find this form on our websites.
- Will there be a dedicated customer service group that will handle these policies or will the representatives who are already in place handle them? Members can call the phone numbers on the back of their ID cards to reach their Customer Service departments. Providers should use service tools as they do today. Verify benefits and eligibility and check claim status through My Insurance Manager. BlueChoice Provider Service areas are also available to answer inquiries.
- If I am an out-of-network provider that sees a patient with a Marketplace plan, is there any situation in which I can file a claim and get reimbursement? You will need to coordinate with your patients to ensure they understand they can be held liable for charges if the service is neither an emergency or they haven’t completed a Transition of Care form that we approved. We may reimburse you if the service is an emergency or the patient completed a Transition of Care form that we approved. The member may still be held liable for any amounts we don’t pay.
- Where do I file my vision claims for Blue Option members? BlueChoice has contracted with VSP for vision services for Exchange members. VSP is a separate company that provides vision services on behalf of BlueChoice HealthPlan. BlueChoice only offers pediatric vision on all Blue Option plans through VSP. All Blue Option plans include routine adult vision coverage using the Physicians Eyecare Network (PEN). PEN is an independent company that offers a vision provider network on behalf of BlueChoice HealthPlan. Members must visit VSP or PEN network providers to receive vision benefits.
- Where do I file pharmacy claims for Blue Option members? BlueChoice has contracted with Caremark for pharmacy services for Exchange members. Caremark is an independent company that provides pharmacy benefits management services on behalf of BlueChoice HealthPlan. You can contact Caremark for Blue Option plans at800-337-5022.
- If I am in the BlueChoice network today, am I also in the Blue Option network as well? No. You will need to contract separately for us to consider you an in-network provider with the Blue Option networks.
- What is ICD‐10? ICD‐10 is the International Classification of Diseases, Volume 10. On January 16, 2009, the U.S. Department of Health and Human Services (DHHS) released the final rule mandating that all parties covered by the Health Insurance Portability and Accountability Act (HIPAA) must implement the ICD‐10 diagnosis and ICD‐10 procedure codes for medical coding. This mandate applies to all health plans and all medical transactions that currently use ICD codes. Subsequent changes to the mandate have made ICD-10 diagnosis and ICD-10 procedure codes effective for dates of service or dates of discharge on or after October 1, 2015. ICD‐10 codes are more specific and numerous than ICD‐9 codes. The new codes will have a profound effect on almost every aspect of the health care industry. It is imperative for all providers to submit the correct ICD-10-CM codes on claims for dates of service on or after October 1, 2015! To avoid delays in processing or potential requests for medical records, please be sure to code for all patient conditions and not just the primary condition the patient presents.
- What is your ICD‐10 implementation plan? BlueChoice began accepting ICD-10 codes on October 1, 2015 as mandated by DHHS.
- Will all other codes end with the ICD‐10 implementation? The ICD-10 implementation will not affect the use of other codes (CPT‐4, HCPCS, Revenue Codes, Mental Health DSM-5, etc.). ICD‐9 codes will still apply for dates of service or dates of discharge before October 1, 2015. The mandate requires ICD‐10 diagnosis and procedure codes on all inpatient claims with discharge dates on or after October 1, 2015. The mandate requires ICD‐10 diagnosis codes on all professional and outpatient claims with dates of service on or after October 1, 2015.
- Are state and federal health plans (Medicaid, Medicare, FEP, TRICARE) exempt from the ICD‐10 mandate? No, all health plans must comply with the ICD-10 mandate.
- Which electronic transactions will be affected by ICD‐10? ICD‐10 will affect these electronic transactions: 837 I Institutional Medical Claim; 837 P Professional Medical Claim; 270/271 Eligibility Request/Response; 278 Request for Review and Response.
- Will there be changes to the CMS‐1500 (“HCFA”) paper claim form? The CMS-1500 paper claim form (version 02-12) has been changed to accommodate the use of ICD-10 diagnosis codes. You can find information at www.nucc.org.
- Will there be changes to the UB‐04 paper claim form? The National Uniform Billing Committee (NUBC) changed the 2012 UB-04 (v.6) paper claim form to accommodate the use of ICD-10 codes. You can find information at www.nubc.org.
- Can I use ICD‐9 and ICD‐10 codes on the same claim? No, you may not file a claim with both ICD-9 and ICD-10-CM codes. You will need to file ICD-9 codes on one claim, and file ICD-10-CM codes on a separate claim.
- What should I do if our claims are continually rejected or denied for ICD-10 coding? You can use My Insurance ManagerSM to submit ICD-10 compliant claims to our plans or resubmit a corrected claim through your clearinghouse.
- Please explain the qualifier in block 21. Do we enter that on the hard copy claim? Our preferred method is to have you submit claims to us electronically. We have a website available for you to key claims if you do not have systems programmed to electronically submit to us. If you are filing your claims hard copy you should indicate ICD-10-CM coding with a “0” in block 21. The ICD Code Qualifier identifies whether the diagnosis code used on a hard copy paper claim is ICD-9 or ICD-10. ICD-9 codes are identified with a “9” and ICD-10 codes are identified with a “0”.
- Will BlueChoice follow Medicare’s one year allowance to accept all claims as long as the code is in the correct “code family”? CMS is providing a grace period on penalties associated with Medicare Part B claims as long as the codes filed are within the same family. They are still requiring correct coding. BlueCross expects providers to file claims with the correct ICD-10-CM code as of the mandate date, 10/1/2015.
- Will our claims reject if we submit RT/LT modifiers? We still require modifiers (including RT/LT) on procedure codes even if the diagnosis code specifies laterality. Procedure code requirements have not changed.
- Should all claims for dates of service prior to 10/1/2015 use ICD-9-CM codes if we submit the claim as late as October or November? We determine ICD-10-CM claims filing by the date of service. For services provided prior 10/1/2015, you should continue to file with ICD-9-CM codes regardless of when you file the claims to us.
- Are claims processed by date of service or date of claim submission? We process claims by the date of service. We do, however, track the date of submission for reporting purposes (timeliness).
- Will we be able to appeal claims filed with ICD-9-CM codes with DOS after 10/1/2015? If you receive a denial on a claim because you filed an ICD-9-CM code instead of the ICD-10-CM code, you can file a corrected claim with the ICD-10-CM code to have the claim reconsidered for payment.
- Does the ICD-10-CM affect dental codes? This change impacts all dental claims that are filed through the patient’s medical benefit. An example of a dental/oral surgical procedure that we may cover under medical is the extraction of an impacted tooth.
- Will you require external cause of injury codes when we submit ICD-10-CM codes for fractures, sprains or strains on a claim? Yes, you have to report the appropriate ICD-10-CM code that includes the reference to external cause of injury when you submit the claim. The codes corresponding to ICD-9-CM V codes (Factors influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification of ICD-10-CM codes rather than separated into supplementary classifications as they were in ICD-9-CM.
- Will diagnosis and procedure codes change or remain the same? We expect CMS to update ICD-10-CM codes periodically just like the ICD-9 codes have changed in the past. The mandate is specific to ICD-9-CM diagnosis and procedure codes converting to ICD-10-CM. Annual updates are posted in July, effective October 1 of that year through September 30 of the following year. For more information, go to https://www.cms.gov/Medicare/Coding/ICD10/index.html.
- Do you require us to file all ICD-10-CM codes with seven alphanumeric characters? Certain ICD-10-CM categories have applicable seventh characters. We require the applicable seventh character for all codes within the category, or as the notes in the Tabular List instruct. The seventh character must always be the seventh character in the data field. If a code that requires a seventh character is not six characters, you must use a placeholder X to fill in the empty characters. You can find additional ICD-10-CM coding guidelines at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf. This site is solely responsible for the content it provides.
- In a physical therapy office, do we add A, D or S to the end of the codes? Most categories have seventh character extensions that are required for each applicable code, and most categories have three extensions (with the exception of fractures): A = Initial encounter (patient receiving active treatment for injury, such as surgical treatment, emergency department encounter and evaluation/treatment by new physician, e.g., S0195XA - Open bite of unspecified part of head, initial encounter). D = Subsequent encounter (patient received active treatment of the injury and receiving routine care for injury during the healing or recovery phase, such as cast change/removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment, (e.g., S0195XD - Open bite of unspecified part of head, subsequent encounter). S = Sequela (used for complications or conditions that arise as a direct result of an injury, such as, scar formation after a burn, e.g., S0195XS - Open bite of unspecified part of head, sequela).
- Do you require the decimal or not when submitting codes? Yes, we require the decimal only when you submit claims through the Web. We do not require the decimal in the electronic claim and the paper UB-04. It is optional on the CMS-1500 professional claim form and the ADA-JD430 dental claim form.
- What does the “F” in front of the ICD-10-CM code signify? Each alphanumeric digit corresponds to a category (family) of codes in the ICD-10-CM. The ‘F’ is assigned for mental and behavioral health disorders.
- I am curious how ICD-10-CM will affect mental health professionals who are not Medicare or Medicaid providers. Will it change our CPT codes or will you use it in place of DSM-5 diagnosis codes? There is no impact to CPT coding with this mandate. DSM-5® contains both ICD-9-CM and ICD-10-CM codes, therefore for dates of service after 10/1/2015 use the appropriate ICD-10-CM codes. You can find more information about ICD-10 and DSM-5 at http://www.dsm5.org/Pages/Default.aspx.
- Do we need to update diagnosis codes for existing authorizations for ongoing services? No. If you get an authorization with an ICD-9-CM code for care with a begin date of service (DOS) before 10/1/2015, you will not need an update if the end date of service goes beyond 10/1/2015. The existing authorization will remain valid.
- If I have a previous authorization with an ICD-9-CM code for a date of service before 10/1/2015 but then change the patient’s visit to a date after 10/1/2015, do you require me to get a new authorization? Yes, if you change the date of service to a later date after ICD-10 implementation, you will need to get a new authorization.
- If we have a pregnant patient that comes into the office, and we get an authorization for her pregnancy before 10/1/2015, does this mean we have to get a new pregnancy authorization after 10/1/2015? No, you will not have to obtain a new pregnancy authorization.
- For durable medical equipment (DME) rentals, will I need to get a new authorization for service that spans 10/1/2015? For services starting before 10/1/2015 complete the authorization using the ICD-9-CM code. We will require no updates even though you will provide some of the services after 10/1/2015. For services that begin 10/1/2015, you should get an authorization using ICD-10-CM codes.
- If we submit a claim with ICD-9-CM and ICD-10-CM codes is the authorization valid? Yes, the authorization will be valid. You are, however, required to file separate claims for services provided 10/1/2015 with ICD-9-CM codes. We will not accept claims with both ICD-9-CM codes and ICD-10-CM codes on the same claim.
- Should we normally request the diagnosis code along with the CPT code for authorizations? You should always request the diagnosis code when getting an authorization.
- Do you require medical records for authorizations if we don't know the specific diagnosis code? We are not changing the authorization process and associated requirements with the implementation of ICD-10-CM. We do accept general diagnosis codes to complete some authorizations today, however, for those services that require a specific diagnosis code to authorize, we may require medical records.
- Is a level of care and plan of care the same thing? I work for a physical, occupational and speech therapist who uses plan of care. They are different. The level of care applies to inpatient claims for skilled nursing facilities. The plan of care refers to the treatment plan that is specific to the patient and the services being provided based on their diagnosis/condition.
- Will there be a grace period to update the level of care on an authorization? No. Providers should update the level of care on an authorization as they do today.
- Are any medical policies going to change? We review and update medical policies annually but we updated these policies to include the appropriate ICD-10-CM codes that are applicable to each policy.
- Will the changes to the ICD-10 codes affect my contract? If you are a contracted provider, the changes will affect your contract. We have impacts annually for the Diagnosis Related Group (DRG) groupe changes, and this is not anything new for us to handle. The new ICD‐10 codes will make it slightly more complicated, but the modeling and pay schedule reviews/updates are already a routine part of our annual process.
- Will you require new Trading Partner Agreements? We will not require new Trading Partner Agreements.
- How will you communicate to providers any issues with ICD-10-CM implementation? If something goes wrong will BlueChoice send info/updates or will providers have to go to your website? We will add bulletins to BlueChoiceSC.com on the ICD-10-CM page of our HIPAA Critical Center. Our Provider Services call center will also include any ICD-10-CM announcement via the voice response unit (VRU).
- Where can I find the new ICD‐10-CM DX codes? ICD-10-CM diagnosis and ICD-10 PCS procedure codes and updates are available through the CMS website at www.cms.gov/ICD10. You can also visit www.ICD10Data.com, a free medical coding website for current and accurate ICD-10-CM/PCS codes. These sites are not managed by BlueChoice HealthPlan. These sites are solely responsible for the information provided.
Please note: The terms “precertification,” “prior authorization” and “authorization” are used interchangeably but have the same meaning.
Maternity Initiatives FAQs
- Which plans require us to follow the Birth Outcomes Initiatives filing guidelines? The BOI filing requirements apply to all BlueCross BlueShield of South Carolina and BlueChoice HealthPlan plans as well as out-of-state members (BlueCard®).
- Should I submit the American Congress of Obstetricians and Gynecologists (ACOG) Patient Safety Checklist when I file a claim? Complete the checklist and keep it in the patient’s chart. We may request a copy of this for verification.
- Do you give additional reimbursement for filing the UA modifier? Medicaid makes an additional payment for this modifier. We do not give additional reimbursement for filing the UA modifier. We pay for procedures based on each provider’s contracted rate or fee schedule.
- Is the UA modifier required for code 59514? We do not require the UA modifier for code 59514. File whichever modifier is appropriate for this code, based on the guidelines and what is medically appropriate.
- If a surgical assistant is involved, do I file the UA modifier in addition to the assistant modifier? Yes. If an assistant surgeon is providing services, you should file the UA modifier in conjunction with the assistant surgeon modifier (80). You should append modifiers to services as applicable in addition to the BOI modifier based on the BOI filing guidelines.
- Which plans participate in the SBIRT program? All South Carolina BlueCross and BlueChoice® plans participate in the Screening, Brief Intervention and Referral Treatment (SBIRT) program with the exception of:
- Federal Employees Program (FEP)
- South Carolina Health Insurance Pool (SCHIP)
- Plans that do not have maternity benefits
- Out-of-state members (BlueCard)
Effective October 1, 2014, the State Health Plan is also participating with the SBIRT program.
- I’ve provided services to a member whose plan is not participating in the SBIRT program. Should I bill the member? You should not hold members whose plans are not participating liable if you have provided services.
- Should I bill for a referral to treatment if the patient refuses the intervention? Should I bill for the referral to treatment if the patient screening does not yield a positive result? You can bill for the intervention (H0004) if an intervention has taken place and you made or attempted to make a referral appointment while the patient is in the office. If the result of the screening is negative, do not provide a referral and intervention, or bill for them.
- How will BlueChoice determine if I made an actual referral to treatment? If the member’s responses result in a positive SBIRT screening, an intervention and referral should take place. The screening tool includes fields to report the organization or provider to which you referred the member. Be sure to fill out the tool completely. Once Maternity Management receives the completed screening tool, we will assign a case manager to review it. The case manager will follow up with the provider or member as needed and provide additional referral resources to the member if necessary. You should also bill the referral and intervention using the H0004 procedure code.
- If the screening is negative, do I need to submit the referral form? No. You should only submit the SBIRT form if there is a positive result, which requires a referral to treatment and intervention.
- Do I need to file the U1 modifier for H0002 or H0004 for SBIRT services? No. The South Carolina Department of Health and Human Services (SCDHHS) required the U1 modifier previously. It is no longer required as of July 1, 2014, and we do not require this modifier, either.
- Do you accept the HD modifier when filed with H0004? This is how we file for Medicaid. We do accept the HD modifier when filed with H0004, however, it is only required for the H0002 when the screening results are positive and the member requires a referral to treatment.
- Are we required to file claims for the screening or intervention with evaluation and management (E/M) codes for the same date of service as well? We file maternity charges globally. This means there would not be an associated office visit to file at the time of the screening or intervention. No, you are not required to file the E/M codes with SBIRT services. We pay these services separately from maternity care.
- Is there an age restriction for SBIRT? There is not an age restriction for SBIRT. It is important to note that if a member’s plan does not provide maternity coverage for dependents, we will not cover SBIRT for the dependent. Please verify eligibility and benefits prior to rendering services.
- Can family practices participate with SBIRT? At this time, the SBIRT program is specifically applicable to obstetricians and gynecological practices.
- What are requirements for participation with your Centering Pregnancy program? What reimbursements will participating providers receive? Approved practices under contract with the Centering® Healthcare Institute (CHI) are eligible for program participation. The CHI is an independent company that provides wellness education information on behalf of BlueCross and BlueChoice HealthPlan of South Carolina.
Participating providers will receive reimbursement for providing these services:
- 98078 with TH modifier - reimbursement is $30.00 per visit, up to 10 visits total
- 0802F - reimbursement is $175.00 as a one-time retention incentive on or after the fifth visit
These services pay separately from global maternity benefits. You should file the appropriate pregnancy diagnosis code.
- Are the procedure codes used for Centering Pregnancy similar to those used for Medicaid services? Yes, the same procedure codes Medicaid uses also apply for Centering Pregnancy.
- How do I become a Centering Pregnancy program provider? If you are interested in the Centering Pregnancy program, please visit the CHI website at www.centeringhealthcare.org. (This link leads to a third party site. That organization is solely responsible for the contents and privacy policies on its site.) Once you initiate the approval and contracting process with CHI, notify us and send a copy of the contract to Provider Certification at email@example.com.
- Which plans participate in the Centering Pregnancy program? All South Carolina BlueCross and BlueChoice plans participate in the SBIRT program with the exception of:
- Federal Employees Program (FEP)
- South Carolina Health Insurance Pool (SCHIP)
- Plans that do not have maternity benefits
- Out-of-state members (BlueCard)
Effective October 1, 2014, the State Health Plan is also participating with the Centering Pregnancy program.
- I’ve provided services to a member whose plan is not participating in the Centering Pregnancy program. Should I bill the member? You should not hold members whose plans are not participating liable if you have provided services.
- Should we bill the Centering Pregnancy service under the patient’s global maternity or as an encounter? You should bill Centering Pregnancy visits separately from global maternity.
- Will I need to give a 30-40 minute individual assessment with each patient in the Centering Pregnancy group? No. The 30-40 minutes is the estimated time allotted for individual assessments for all of the Centering Pregnancy participants during each session.
- Can midwives conduct Centering Pregnancy visits if the Centering Healthcare Institute contracts and approves the practice? Will you cover and reimburse the visits the same as if a physician conducts the visits? Certified nurse midwives (CNM) as well as physicians and nurse practitioners (NP) can conduct Centering Pregnancy visits.
- I have a patient who has been participating in Centering Pregnancy prior to the July 1, 2014 start date. Do I count visits prior to July 1 and bill the retention incentive (0502F) for the fifth visit? If you have a patient who began participation in the Centering Pregnancy program prior to July 1and is continuing to participate, you can bill for the retention incentive. File both 0502F and 99078. Complete the Centering Pregnancy Verification form available at www.BlueChoiceSC.com. This form alerts us that a member has had Centering Pregnancy visits prior to our implementation of this program. It will ensure we process claims for the retention incentive.
- Are we required to file claims for Centering Pregnancy session with E/M codes for the same date of service as well? We file maternity charges globally. This means there would not be an associated office visit to file at the time of the screening or intervention. No, you are not required to file the E/M codes with Centering Pregnancy visits. We pay these services separately from maternity care.
- Is there an age restriction for Centering Pregnancy? There is not an age restriction for Centering Pregnancy. It is important to note that if a member’s plan does not provide maternity coverage for dependents, we will not cover Centering Pregnancy services for the dependent. Please verify eligibility and benefits prior to rendering services.
- Can family practices participate with Centering Pregnancy? Centering Pregnancy is specifically applicable to obstetricians and gynecological practices that are approved or under contract with the CHI.
- Where can I find additional information about your maternity initiatives? Information about our maternity initiatives is available on our website, www.BlueChoiceSC.com.
- How does the Moms Support Program work? If an expectant mother has been referred to Companion Benefit Alternatives (CBA) for services, the member can be enrolled in the Moms Support Program. CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueCross and BlueChoice. CBA designed this program to help expectant and new mothers who may be experiencing depression or anxiety. The program provides guidance, support, assessment and case management to mothers.
- How can I be certain the OB/GYN Report Card gets to the appropriate person in my practice? You can contact your provider advocate and give him or her the information of the person who should receive the report card. You can also contact Provider Education by emailing firstname.lastname@example.org or calling 803-264-4730.
BlueCross® BlueShield® of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Mental Health FAQs
- Are prior authorizations no longer required for mental health benefits in all BlueChoice Plans? A few plans may continue to require precertification. Contact Companion Benefits Alternatives (CBA) to verify by calling 800-868-1032. CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueChoice HealthPlan.
- Who can I contact to help a patient get mental health assistance? Contact CBA for assistance by calling 800-868-1032.
National Imaging Associates (NIA) & Radiation Oncology FAQs
- How quickly can a provider get a precertification when using RadMD.com? Generally, within two business days after NIA receives a request, it will make a determination. In certain cases, the review process can take longer if NIA needs additional clinical information to make a determination.
- Whose responsibility is it to initiate a precertification? The ordering physician has the responsibility to initiate a precertification.
NIA is an independent company that provides utilization management services on behalf of BlueChoice HealthPlan.
Pharmacy Management FAQs
- Will durable medical equipment (DME) and pharmacy offer the same benefits for diabetic test strips? Yes, you must use OneTouch test strips. We require prior authorization for all test strips other than OneTouch. Please check the patient’s benefits via My Insurance ManagerSM.
- Will prior authorization requirements for pharmacy be the same across all BlueChoice Plans? All BlueChoice groups have the prior authorization program. Visit prescription drug information and lists on our website for details.
- How can I complete a precertification request for two or more procedures -- such as a colonoscopy and endoscopy -- via My Insurance ManagerSM? You are unable to complete a precertification request for more than one service on a single entry using My Insurance Manager. Once you have chosen your request type and select one service, you will continue through the remaining precertification request screens to completion. At that time, you may begin a second request.
- How can I have diagnoses added to the Fast-Track Request Option in My Insurance Manager? Contact Provider Relations and Education to have a diagnosis-procedure combination considered for adding to the Fast-Track Request Option in My Insurance Manager.
- At times when I call the Plan to get a DME precertification, I’m told the member’s plan does not require an authorization for the item. However, when the claim is filed it is denied for no authorization. Why? Always verify benefits and eligibility to find out if an item requires precertification. Generally, an authorization number is required for DME supplies over $500.
- How can I edit the default diagnosis code when requesting a precertification for a procedure via the Fast-Track Request Option? Users are unable to edit the diagnosis code when using the Fast-Track Request Option; this may be done via the Customized Authorization Request Option. My Insurance Manager defaults to a standard diagnosis for Fast-Track Request Options but it does not prevent the requestor from gaining an authorization number.
- Can I go directly to Novologix to complete a precertification request? No, you cannot go directly to the Novologix portal. There is only single sign-on access through My Insurance Manager using the member’s ID.
Provider Credentialing FAQs
- Should I go through the provider credentialing process or provider contracting upon initial contact with BlueChoice? You should go through the credentialing process first if you want to be in network. Find the forms you need to become part of the BlueChoice network on our website. You can contact Provider Enrollment email@example.com to determine what documents you need if you are not familiar with the credentialing paperwork. This will prevent you from submitting duplicate documents or unnecessary paperwork.
- When does the provider effective date begin – upon the signature date of the provider contract or upon completion of the provider credentialing review date?The effective date for networks begins upon completion of the contract review. We base the BlueChoice effective date (date we add the provider to the file) on the signature date on the provider’s application.
- What are the differences between individual credentialing and group credentialing? How does this impact a non-participating physician in a participating group? The Provider Enrollment department only handles the individual network credentialing process. Our Provider Contracting area negotiates group contracts for BlueChoice networks. You should contact your Provider Contracting representative for clarification about group credentialing.
- If I am a mental health provider, should I go through the credentialing process for both BlueChoice and CBA? You will not need to complete the credentialing process for BlueChoice. Credentialing for mental health practitioners is coordinated through CBA and covers the networks for the BlueChoice network. CBA is a separate company that admibisters mental health and substance abuse benefits on behalf of BlueChoice.
- How long does the credentialing process take once I submit all required documentation? Why do I have to supply the date I submitted the application to find out my credentialing status? The 90-day review period begins after we receive all required documentation. If an application is missing information or if the application is incomplete, we pend the application and the Provider Enrollment department will request the information from you. Once we receive the information, we send the application to review.
- Whom should I contact if I have a question about the status of my provider credentialing application? For BlueChoice provider credentialing questions, please email firstname.lastname@example.org. You can email CBA at email@example.com for questions about mental health provider credentialing.
- What provider credentialing form should I use when I have sold the practice to a new physician owner? You should submit the Application for Group/Clinic/Institution to file claims or change Employer Identification Number (EIN). You can find this form on the Update Provider Information page of our website.
- What is the process if I am already credentialed and am affiliated with a facility and want to be affiliated with another separate facility? What documentation do you require? You will need to submit the Request to Add Practitioner Affiliation form, the Authorization for Clinic/Group to Bill for Services and the Appendix D and Hold Harmless forms if the group participates with BlueChoice.
- Am I required to be accredited with a professional association of my specialty (ex: American College of Radiology)? No, this is not a requirement for our provider credentialing process.
- Does BlueChoice use a separate vendor for credentialing (ex: Council for Affordable Quality Healthcare)? BlueChoice does not use any vendor for provider credentialing enrollment or updates. We use our own credentialing department for provider verifications to meet the National Committee for Quality Assurance (NCQA) credentialing standards.
- How long is the credentialing process? Provider credentialing has a 90-day review period to process applications. It may be prolonged, however, based on the completeness of the application. If we require additional information, this will extend the credentialing process.
- If a physician is licensed and affiliated with a participating practice but not yet credentialed with BlueChoice, can the physician see patients? The physician can see patients. Physicians should not, however, begin filing claims to BlueChoice until they have confirmation that we accepted their credentials.
- How often is recredentialing required? Providers go through the recredentialing process every three years. Per the Center for Medicare and Medicaid Services (CMS) mandate, however, you may hear from your provider advocate to verify that your practice and physician information is up to date on an annual basis. You should respond to these requests to ensure your information is current and accurate.
- Can I be credentialed if I am missing South Carolina licensure? No. You must have South Carolina licensure to be credentialed with BlueChoice.
- How far in advance of a physician signing with our practice should I submit the application to BlueChoice? As soon as a provider knows he or she will require credentialing services -- such as a new provider or new location -- the better it is to notify us at that time. We are able to give a future date for an application received. For example, a provider can start the credentialing process now for a provider adding a new location months later.
- Is the facility or the physician notified when it is time for re-credentialing? The facility never receives a letter about a physician that is due to be re-credentialed. We send re-credentialing letters to physicians. If a facility has a designated department or contact person that handles credentialing, we send the notification there. If a credentialing vendor is designated (ex. EmCare) our credentialing area will contact the vendor. If the proper contacts are not receiving these letters, please update your contact information with us.
- When a provider leaves a practice, do BlueCross and BlueChoice note the separation date as the practitioners' last day of employment or the date the application was received? Our concern is there are claims pending they will be denied. We terminate a provider one day beyond the required (requested) termination date. Any claims submitted for dates of service prior to the provider leaving will be processed for payment.
- Are nurse practitioners (NPs) also required to complete section III.1 of the credentialing application (Education/Training/Hospital Privileges)? Yes, NPs should complete section III, parts 1 and 2. Part 3 is not applicable to NPs.
- Do BlueCross and BlueChoice recognize physicians working under Locum Tenen? We permit practitioners to work in this capacity for three months or less. The provider group must take responsibility to be sure the practitioner who is under Locum Tenen has the appropriate credentials/experience, etc. to perform the procedures assigned to him. If the practitioner will be working with the practice for more than three months, then provider credentialing needs to affiliate, credential, etc. as we would a provider joining that practice.
Provider Web Tools FAQs
- What is My Insurance Manager? My Insurance Manager is an online tool you can use to access: Benefits and eligibility, claims entry, preauthorization request and status, claims status, EDI claims reports, remittance information, other health insurance, view primary care physician, your patient directory and your mailbox. My Insurance Manager is safe, secure, simple and best of all, it’s free!
- How do I verify a member’s benefits and eligibility? Check eligibility and benefits by logging into My Insurance Manager.
- What is a Superbill? The Superbill tool in My Insurance Manager is ideal for providers who want to submit primary claims for one date of service only. You can create and store your Superbill online, then use it to submit a professional Web claim with a minimum of keystrokes. It takes only seconds to submit a claim to us and you will receive instant claim disposition!
- How do I check the status of a claim? You can check claim status in My Insurance Manager using the Claim Status function. For information on how to use any features on our website, visit our Provider Tools section or contact your provider advocate.
- Should I re-submit a claim if I do not receive payment? No. If you have not received payment for a claim, do not resubmit the claim. We will deny it as a duplicate. This also causes member confusion because of multiple EOBs. You should always check claim status through My Insurance Manager. In some cases, a claim may pend because medical review or additional information is necessary. We will contact you when we need additional information to finalize the claim.
- Is there any other way we can communicate directly with BlueChoice’s Provider Services department? Use of our automated response tools is the most efficient way to get patient benefit information and claim status. Provider Services representatives are only available for inquiries that you cannot get answers to by querying the voice response unit (VRU) or using My Insurance Manager. Ask Provider Services is a feature in My Insurance Manager you can also use to have a Provider Services representative respond to your question. My Insurance Manager requires the patient’s ID and date of birth (DOB) to search for benefits.
- Can My Insurance Manager allow providers to search for member benefits using any combination of their full name, DOB or ID? At this time that is not an available feature in My Insurance Manager.
- Does BlueChoice have a Web link or listing with updated alpha prefixes for all Blue Plans? We do not have an all-inclusive list of each home Plan’s alpha prefixes. To determine which network you should use for a specific alpha prefix, you can use the National Doctor and Hospital Finder.
- How does My Insurance Manager differ from the secure provider portal on the BlueChoice HealthPlan Medicaid website? The ProviderAccess provider portal available at www.BlueChoiceSCMedicaid.com is very similar to My Insurance Manager. It allows providers to review claims, check if a member is eligible and print out reports. The biggest difference is you cannot get BlueChoice HealthPlan Medicaid information through My Insurance Manager or get any commercial lines of business for BlueChoice information using ProviderAccess.
- What should I do to avoid claim denials or withheld payments because of a patient’s missing other health insurance update and/or accident questionnaire?At the beginning of each new year, we require our members to update their other health insurance (OHI) information. You can make it easy by giving members computer access right in your office. Ask them to visit our website and log into My Health Toolkit® to update their information. If you prefer, you can download a hard copy of the Other Health/Dental Insurance Questionnaire. You can save this form on your computer and email it to members as needed. A Spanish version of this form is also available. FEP members do not currently have access to the form in My Health Toolkit and will need to complete a hard copy of the FEP Other Health Insurance Questionnaire. Members should complete a Subrogation Questionnaire when they receive treatment for an injury or illness that is work-related or the result of an accident. All of these forms are available on our website.
- How do I file a secondary claim using My Insurance Manager? To file a secondary claim, from the Patient Care menu, choose either Professional or Institutional Claim Entry. On the Plan Information page, for “Is the selected plan the primary payer?” choose No. Continue entering your provider, patient and claim information. After you’ve entered your claim line information, you will be asked for the other payer information. You can choose another payer by selecting the link or manually entering the payer information. Enter the patient’s other insurance information in the required fields. You have the option of entering the Other Payer Claim Information and Adjudication Information. For professional claims, we recommend you enter the other payer money as a line-level adjustment. For institutional claims, we recommend you enter the other payer money as a header-level adjustment. Please note: We automatically default to these options based on whether you choose to file a professional or institutional claim. Enter the amount under Payer Paid. The Other Payer Line Selection page lets you review the other payer information you’ve entered and make corrections if necessary. If the information is correct, select Continue and you can review all the claim information before submitting it for processing.
- How long does it take to get a referral or authorization? You should receive a response in 24-48 hours.
- Is there a one-question limit when using STATChatSM? No. You can ask as many questions as you like related to one member’s account. Using STATChat rewards you for using our website to try to get the information you need. The patient information, however, prepopulates onto the Provider Service representative’s screen, so he or she is restricted to only answering questions related to the member from your original inquiry.
- Have you added home health to the Fast Track option on the Web? No, home health is not available as a Fast Track option.
Quality Initiatives FAQs
- How do I find out more information about becoming a Patient Centered Medical Home (PCMH) provider? Because there are several criteria that a provider has to meet to become a PCMH, a BlueChoice representative will work closely with you to determine your candidacy. Please email your interest to noreen.o’firstname.lastname@example.org.
- Should I file the appropriate H-codes with an Evaluation and Management (E/M) visit for Centering Pregnancy? No, you should not file an E/M procedure code with the H-code for patients participating in the Centering Pregnancy program.
- Do Consumer Assessment of Health Plans and Systems (CAHPS) and/or Healthcare Effectiveness and Data Information Set (HEDIS) ratings affect claims reimbursement? No, CAHPS and HEDIS do not currently affect reimbursement. These could, however, become the standards for future quality-based reimbursements.
- Does HEDIS count toward DME supplies? HEDIS measures do not apply toward DME supplies.
- Is HEDIS required for all specialties (example: fertility)? HEDIS is not a requirement for specialty practices. Specialty practices, however, can gain NCQA recognition for successfully coordinating patient care with their primary care colleagues. HEDIS does not measure infertility services.
- What are requirements for participation with your Centering Pregnancy program? What reimbursements will participating providers receive? Approved practices under contract with the Centering® Healthcare Institute are eligible for program participation. The Centering Healthcare Institute is an independent company that provides wellness education information on behalf of BlueChoice HealthPlan. Currently, this initiative applies to all BlueChoice plans except FEP, out-of-state (BlueCard) members, State Children’s Health Insurance Program (SCHIP) and plans that do not have maternity benefits. Participating providers will receive reimbursement for providing these services: 99078 with TH modifier – reimbursement is $30.00 per visit, up to 10 visits total. 0502F – reimbursement is $175.00 as a one-time retention incentive on or after the fifth visit These services pay separately from global maternity benefits. You should file the appropriate pregnancy diagnosis code.
- Are the procedure codes used for Centering Pregnancy similar to those used for Medicaid services? Yes, the same procedure codes that are used with Medicaid also apply for Centering Pregnancy.
- Why does BlueChoice share Gaps In Care (GIC) reports with providers? A care gap occurs when a member has not received a preventive health service. We collect and share this data with our providers to have you reach out to those GIC patients to receive those missed and/or undocumented preventive health services. Closing these gaps also help to meet HEDIS requirements while improving the overall health of your patients, our members.
- Can a practice include more than four diagnoses codes when submitting claims electronically? Yes, for claims filed electronically we are able to accept up to 12 diagnosis codes for professional claims, and up to 25 diagnoses codes for institutional claims. This will not change with ICD-10 implementation in October. You should contact your clearinghouse if you are experiencing trouble transmitting more than four diagnoses codes.
- Are specialists expected to report all diagnosis codes for HEDIS? No, we do not expect specialists to report all diagnosis codes for HEDIS. Our efforts to close patient care gaps concentrates on claims data from primary care physicians.
- How can I receive a GIC Provider Report? You can receive your practice’s Gap In Care Provider Detail and/or Summary Reports from your provider advocate. It can be delivered to you securely by email or fax. It is not available via My Insurance Manager at this time.
State Health Plan (SHP) FAQs
- Why does it appear that SHP claims are paid timely for lab procedures but a routine annual gynecological visit denies or delays payment? The lab claim (Standard Plan) has to pay first. BlueChoice is unable to reduce the amount of time it takes to reimburse providers unless the claim is filed sooner.
- Will SHP cover the shingles vaccine as a preventive service in 2015? In 2015, the shingles vaccine Zostavax and the administration fee are free to Savings Plan and Standard Plan members age 60 and older. Remember: Zostavax, like all prescription drugs, is covered only if the member gets it at a participating pharmacy. Some network pharmacies administer the drug.
- Where can I find the SHP fee schedules? The 2015 SHP fee schedule is available to download in an Excel file format. The new schedule became effective January 1, 2015. To download the file, you must first log into My Insurance Manager. If you have never used My Insurance Manager before, visit our Provider Tools section to learn more. Once you have logged in, scroll down the page and find the "State Health Plan Fee Schedules" heading.
- Why doesn’t SHP cover 18 year old checkups? The SHP is a self-insured group, which means the Public Employee Benefits Authority (PEBA) regulates the benefits. PEBA contracts with BlueChoice to administer those benefits and process claims. The SHP does offer some wellness incentive programs for adults ages 18 and older. Generally, the State plans cover procedures recommended by the U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention that systematically reviews what treatments are effective. It does not recommend that individuals have an annual physical.
- How does SHP pay when it is the patient’s secondary insurance? The SHP – Standard Plan and Savings Plan options – works in these ways when it is filed as secondary insurance: For a medical or a mental health/substance abuse claim, the explanation of benefits from the primary plan must be filed with BlueChoice. For prescription drug benefits, a member must present their card for primary coverage first. Otherwise, we will reject the claim because the pharmacist’s electronic system will show that the SHP is secondary coverage. After the pharmacy processes the claim under the primary coverage, file a paper claim through Catamaran for payment of any secondary benefits. Prescription drug claim forms can be found on the PEBA Insurance Benefits website at www.eip.sc.gov. The SHP will pay the lesser of: 1) what it would pay if it were the primary payer; or 2) the balance after the primary plan’s network discounts and/or payments are deducted from the total charge.
- What is the Wellness Incentive Program for adults? This program is a wellness initiative. PEBA is waiving the copayments for specific generic drugs and diabetic supplies as part of an effort to encourage subscribers and their covered dependents with diabetes or cardiovascular disease to better manage their conditions. The hope is to improve the lives of members and to help reduce health care costs over time. Eligible SHP members and their covered spouses and dependents can participate in the program. Please contact your provider advocate for further details.
BlueCross® BlueShield® of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.