Quality Initiatives FAQs

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 HealthPlan representative will work closely with you to determine your candidacy. Please email your interest to Noreen O'Donnell at mg93@bcbssc.com or call 803-382-5408.

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®. 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.