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An Independent Licensee of the Blue Cross and Blue Shield Association.
2013 Hospital Quadrant Meetings
Blue Cross and Blue Shield of Kansas
August 2013
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Today's Presenters
Connie Winkley
o Education Coordinator, Institutional Relations, BCBSKS
Denny Hartman, CPC
o Provider Representative for Southern Kansas, Institutional Relations, BCBSKS
Cindy Garrison, CPC
o Provider Representative for Northern Kansas, Institutional Relations, BCBSKS
BCBSKS Marketing Representative
Marie Burdiek
o Account Representative, Electronic Data Interchange (EDI), BCBSKS
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Meeting Agenda
New BCBSKS Institutional Provider (IR) Staff
Availity Web Portal
ICD-10 Updates
Electronic Inpatient Precertification
2014 Policies and Procedures
Hospital Abstracts
2014 Quality- Based Reimbursement Program (QBRP)
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Meeting Agenda
Miscellaneous Billing Guidelines
Non-contracting Provider Billing Procedures
HealthCare Reform (HCR) Products
Top 10 Denials
New Services/New Procedures
Electronic Data Interchange (EDI)
Q & A
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Institutional Relations (IR) Org Chart
Denny Hartman, Provider Rep
Hospitals in Southern KS
Cindy Garrison, Provider Rep
Hospitals in Northern KS
Teresa Van Becelaere, Manager
Institutional Relations
Angie Strecker, Director
Institutional RelationsDona Hewes
Administrative Coordinator, IR
Fred Palenske, Senior VP
Provider and Government Affairs
Connie Winkley
Education Coordinator
Janne DentonContract Consultant & Specialty Provider Rep
Katie Dennison
Claims Research Analyst
Brent Matile
Quality Reimbursement Analyst
Melanie Moriarty
Administrative Assistant (Topeka)Cheryl Carner
Administrative Assistant (Wichita)
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Introducing New BCBSKS Institutional Relations Department Staff
Janne Adams-Denton
oContract & Specialty Provider
Consultant
o785-291-8813
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Introducing New BCBSKS Institutional Relations Department Staff
Katie Dennison
oClaims Research Analyst
o785-291-8849
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Introducing New BCBSKS Institutional Relations Department Staff
Brent Matile
oQuality Reimbursement Analyst
o785-291-6593
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Availity Web Portal
Availity and BCBSKS began their business relationship in
2011
BCBSKS moved their member's eligibility and claim status
information for providers to access on the Availity web
portal in March 2012.
BSBSKS has educated providers since March 2012 on
Availity through newsletters, workshops and webinars
Effective August 19, 2013 providers must log in to Availity
to access BCBSKS member's secure information.
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Availity Web Portal
BCBSKS Member's eligibility and claims status will only be
available on the Availity web portal effective 8/19/13.
Other secure member information remains on BlueAccess;
however a provider must log on to Availity to get to BlueAccess.
Questions on Availity?
• BCBSKS Provider Rep
o Denny Hartman or Cindy Garrison
• Education Coordinator
o Connie Winkley
• Availity
o 1-800-Availty (1-800-282-4548)
o By email – [email protected]
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ICD-10 Updates
BCBSKS launches ICD-10 Provider Web Page –May 2013
o Provider resource in preparation for the U.S. Healthcare
industry's change from ICD-9 to ICD-10 for medical
diagnosis and inpatient procedure coding.
o Provides ICD-10 information through newsletters,
training opportunities, web links and FAQs.
o Providers can submit questions regarding ICD-10 and
BCBSKS will provide answers to the questions through
the FAQ link.
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ICD-10 Updates
BCBSKS Readiness for ICD-10:
o Completed impact analysis and prepared for October 1 deadline
o Completed review of Medical Policies and system changes
o Working on systems upgrade for review phase
o Continue to work on mapping the ICD-9 codes to ICD-10 codes in our claims
system.
End-to-end testing
o Facility submits an ICD-10 coded claim to BCBSKS and BCBSKS will send
acknowledgement to provider with the outcome of the claim
o If claim is processed as a clean claim, then BCBSKS will produce a
remittance advise for the provider.
o BCBSKS will track every one of these claims to ensure they make it through
the system and let the provider know whether or not they hit any edits.
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ICD-10 Updates
Additional ICD-10 Information:
o BCBSKS has identified some claims scenarios that we will
want to test with providers and likewise, providers should
bring specific claim examples to BCBSKS that they want to
test during the End-to-End testing period. This will be more
of a claim by claim test versus a batch file.
oMore information on specific processes will be
communicated at a later date.
o Providers should contact their BCBSKS Institutional Provider
Representative if interested in testing for ICD-10.
Cindy Garrison – 1-785-291-8862
Denny Hartman – 1-316-269-1602
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Electronic Inpatient Precertification
Electronic Precertification required for inpatient care :
o Prior to admission
o The day of admission
o The first working day following a weekend or holiday
Electronic Precertification is a prerequisite to BCBSKS
Quality Based Reimbursement Program (QBRP)
InterQual upgrade to 2013 version in July 2013.
o Notice of upgrade sent to providers through eNews
o Details can be found on the BCBSKS Precert Web Page
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Electronic Inpatient PrecertificationBCBSKS Electronic Precert Contact Information:
Availity Website Access and
General Inpatient Precertification
and InterQual Information
Connie Winkley –
Education Coordinator1-785-291-7236
Coding for Inpatient
Precertification
Denny Hartman – BCBSKS Provider
Rep for Southern KS Hospitals 1-316-269-1602
Coding for Inpatient
Precertification
Cindy Garrison – BCBSKS Provider
Rep for Northern KS Hospitals1-785-291-8862
Clinical Questions about InterQual
and Medical CriteriaBCBSKS Precertification Department 1-800-782-4437
Problems with BCBSKS Secure
Access (BlueAccess)BCBSKS Help Desk 1-800-472-6481
Problems with the Availity Web
PortalAvaility Client Services 1-800-AVAILITY
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Electronic Inpatient Precertification
Electronic Precert Changes coming in 2014
o Implementation of Electronic Provider Access (EPA) on January
1, 2014 which will enable providers to be routed from Host to the
member's Home Blue Plan for pre-service review. The Blue
Cross and Blue Shield Association will facilitate the routing by
providing a web service that will identify the appropriate Home
Plan by alpha prefix.
o There will be approximately 33 Blue Plans that will have
electronic pre-service review for inpatient services available to
out-of-area providers.
o Note: name change to Pre-service review which includes
precertification, pre-authorization and prior approval.
o Further information and provider education coming soon.
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2014 Policies & Procedures
Replaced the reference to each individual product
with all benefit programs, indemnity plans and self-
insured plans
Clarified amounts billable to the patient
Reworded for ICD-10 claims submission
requirements
Request for information; Medical Records
Request for information; Quality of Care
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2014 Policies & Procedures
Amendments to signed Provider Agreement
o Providers permitted to disclose PHI for
purposes of treatment, payment or
operation
o Insolvency, Receivership and Liquidation
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Kansas Health Data Systems (KHDS)Hospital Abstracts
KHDS is a unique department within Institutional Relations.
KHDS is responsible for the processing of Medical Record
abstracts and providing facility education to efficiently
complete abstracts for all contracting hospitals in Kansas
who submit inpatient claims.
An abstract is a separate document, which must be present
for BCBSKS inpatient claims to process completely
Hospital abstracts are designed to confirm the accuracy of
the MS-DRG.
Paid claim = abstract
Audits are done and adjustments are made, as needed
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Kansas Health Data Systems (KHDS)Hospital Abstracts
Contractual obligation with BCBSKS
Transmitted monthly
o45 days from the end of each month
Hospital builds file and submits via:
oVendor
oKey in using My Ability or IVANS
Option to send BCBSKS only or send for all payers
KHDS sends inpatient data to KHA for those submitting
all payer abstracts
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Kansas Health Data Systems (KHDS)Hospital Abstracts
KHDS Contact Information:
oDeanna Karle, KHDS Manager, 785-291-8702
oTodd Colglazier, KHDS Senior Field
Representative, 785-291-8830
Email KHDS staff: [email protected]
KHDS website:
www.bcbsks.com/khds/index.htm
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2014 Quality Based Reimbursement Program (QBRP)
Mailed end of July
First reporting due November 15, 2013
Second reporting due May 15, 2014
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2014 Quality Based Reimbursement Program (QBRP)
Paper copy to CEO’s
QBRP Web page and Web based form – coming soon!
Link at top of form to explain each measure and how to
calculate
Providers won’t fill out every section
Hover over the numerator/denominator boxes for an
explanation
IMPORTANT: PRINT SCREEN BEFORE SENDING!
Access to web QBRP form will end on the deadline
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General Claims Issues
Multiple encounters (2 ER visits) on the same
day = 2 claims
Multiple services same day
Observation (OBS)
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Non-Contracting Provider Billing Procedures
Transfers or Referrals
o Facility refers or outsources the service to another
provider.
o The contracting facility is required to file for all
services rendered and the member is held harmless
for the use of a non-contracting provider.
o The contracting facility would make payment
arrangements with the non-contracting provider to be
paid for their services.
o The non-contracting provider should not bill the
member or BCBSKS.
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Top 10 Denials – 2012Claim
Adjustment
Reason Code
Remit
Remark Code
Reason
18 None Duplicate Claim/Service
96 N130 Non-covered service(s)/Charge(s)
16 N202
M118
M58
Claim/service lacks information which is needed for adjudication. Additional
information/explanation will be sent separately
97 MA67
N185
M49
M86
A corrected claim or a claim that needs to be combined with another claim
has been received and will adjudicated or benefit for service is included in
the payment/allowance for another service/procedure
27 N30 Service(s)/charge(s) incurred after contract terminated
96 N216 Non-covered charge(s)
115 None This claim or line has been cancelled
32 / 35 / 30 N30 The patient was not eligible for benefits at the time of service.
B11 None Claim has been forwarded to the local Blue Plan for processing.
23 M43 The Medicare payment is greater than or equal to the maximum allowable
payment under the patient's contract.
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Top 10 Denials – 2013
TOT CHG CLM LI
CT
Claim
Adjustment
Reason Code
DS
147,332,717.33 127973 97 Corrected Claim
13,270,124.86 70090 23 The impact of prior payer(s) adjudication including payments
and/or adjustments.
73,099,992.76 65265 18 Duplicate claim/service
110,477,286.98 43782 131 Claim specific negotiated discount (Plan 65 Select)
41,810,404.81 35468 16 Claim/service lacks information which is needed for
adjudication
2,550,708.93 31395 96 Non-covered charge(s) (Plan 65)
10,284,562.70 22026 27 Expenses incurred after coverage terminated.
7,422,067.56 20631 97 The benefit for this service is included in the
payment/allowance for another service/procedure that has
already been adjudicated.
7,154,902.49 14091 96 Non-covered changes(s)
5,663,574.48 12890 16 Claim/service lacks information which is needed for
adjudication.
TOTAL CLM
LI CT
571491
DOS = 1/1/13 – 7/1/13
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New Services / New Procedures
New or Expanded Services
o Notify BCBSKS of any new or expanded service(s).
The purpose of this notification is to allow BCBSKS to
determine if the new or expanded service is covered under
the terms of the various member contracts.
New Techniques and Technology
o Maximum allowable payment (MAP) for new techniques and
technology will be based on existing comparable procedures.
o Additional allowances will be considered if there is significant
improvement in safety or efficacy of patient care.
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Questions?
Thank you for
attending today's
workshop!
