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BlueCare Tennessee Provider Administration Manual

Important Changes: Effective January 1, 2024

The following table highlights a number of important upcoming changes to guidelines and policies in this quarter's BlueCare Tennessee Provider Administration Manual.

Note: All changes reflected in the Manual are not listed in this table.

Section # and Title I. Introduction IV. Benefits

V. Billing & Reimbursement

Affected Page(s)

Modification

11 18 55 60 62 79 85-86

86

93 110

133 187

? Added discrimination language to 7th paragraph. C. General Information

? 1. Interpretation Services ? Updated language in 7th paragraph.

A. Covered Benefits 20. Home Health Care Services ? Removed "Medical Social Services" bullet/language and updated the last two bullets language by adding or removing "and". 22. DME ? Updated two broken links 26. Therapy and Rehabilitation Services ? Updated language by adding "a" and "alternative" to the note.

F. General Billing and Reimbursement Information ? Added Note for coding, billing, and reimbursement hierarchy.

12. Quest Diagnostics Laboratory Billing Guidelines ? Updated language since Effective July 1, 2023, providers no longer must use a since source laboratory vendor (Quest Diagnostics) for lab testing services.

13. BCT Laboratory Testing Code Reimbursement Policy ? Updated language in policy referring to the website for policies and removed policy names as they may change with quarterly updates from Avalon.

18. Division of TennCare Budget Memo Guidelines ? Added Note for reimbursement of stand-alone vaccine counseling.

H. Completing CMS-1500 Claim Form 3. Form Contents and Description ? Block 24B ? PLACE OF SERVICE: Added new assigned POS 27 ? Outreach site/street to the grid.

I. Specific CMS 1500 Claim Form B&R Guidelines 23. MUE's ? Updated broken link (2nd link)

M. CMS-1450 Claim-Specific 17. Rehabilitative Care ? RC 0270 Non-Routine Supply grid ? removed code A4397 and replace with codes A4436 and A4437.

N. Institutional Claim Billing and Reimbursement Guidelines changes for Providers contracted with BCT Base Fee Schedule Version 7 or later.

Section # and Title

Affected Page(s)

Modification

VII. Member Policy VIII. UM Program

XI. Quality Improvement Program XII. Provider Agreement

XIV. Preventive Care XV. Behavioral Health Services

194-196

196 200

5. Reimbursement Policy and Billing Guidelines for Separately Reimbursed Facility Drug Fee Schedule ? Replaced SR Facility Drug Fee Schedule Policy to allow for new language for SR fee schedules 3 & 4.

6. Reimbursement Policy and Billing Guidelines for the Advanced Therapeutic Fee Schedule ? Added new Advanced Therapeutic FS Policy for cell/gene therapy.

Q. OptumRX Programs ? Updated broken link in 1st paragraph.

213 E. Member Appeals ? Updated broken link in #7.

219 223 235 237

252 253

265 266 267

275-276, 278, 280 289-290

298 301

307

D. Outpatient Services Requiring Prior Authorization ? CRT - Updated last bullet with new hyperlink to full list of lab testing codes requiring PA.

G. DME, O&P, Medical Supply Prior Authorization Requirements ? Added repairs PA language and bullets. ? Breast Pumps - Updated two broken links.

R. Services Subject to Retrospective Claims Review and Focused Review ? ASH - Updated broken link in 2nd paragraph.

V. Emergency Services ? Prescription Drug Emergency Services - Updated broken link in 2nd paragraph.

C. Structure ? 3rd set of bullets ?added bullet and language for "Annual review of Quality program documents". ? Committee Structure ? Removed "HEDIS Operational Oversight Workgroup" and added Dept. of Child Services Clinical Advisory Panel" to bulleted list.

? Added language to 1st paragraph regarding provider agreements contracts or templates and revisions approval required by TDCI and other requirements.

? Monthly Screening Requirements - Updated language in 1st paragraph. ? Provider Appeals Procedures ? Replaced incorrect link title and link in 3rd

paragraph for "TennCare & CoverKids1 Programs Request to Commissioner for Independent Review of Disputed Provider Claim form" C. TennCare Provider Agreement Requirements ? Updated language to #43, 46, 72, 74, 78 within the Provider Agreement requirements list.

B. Preventive Care Guidelines ? Updated link in 4th paragraph and 6th paragraph.

D. Guidelines of Periodic Health Assessments Records ? Dental Preventive Care ? Updated link in last paragraph

B. Covered Behavioral Health Services ? Updated grid - Inpatient, residential & outpatient substance use disorder benefits: Removed cross reference to language regarding services in a licensed substance use disorder residential treatment facility may be substituted.... One cross reference remains. 12. Prior Authorizations ? Removed "(other than inpatient)" and "for services other than inpatient" as IP is now included.

Section # and Title

Affected Page(s)

Modification

XVI. Provider Networks XVII. Credentialing

XVIII. CoverKids XX. TennCare Kids

314 317

320

330 330 334-335

335

336-344

345-351 360

360-361 362 362

373 373 373 374 385 386 387

398

G. Buprenorphine Enhanced and Supportive Medication Assisted Recovery and Treatment

? Added hyperlinks to PC 771 and PC 761. J. Access and Availability of Behavioral Health Services

? Added "Tennessee" and "T in TDMHSAS" to language in 1st paragraph. K. BlueCare Behavioral Health Quality Management:

3. Site Visits for Quality Reviews and Treatment Record Audits ? Updated title to "Site Visits for Quality Reviews and Quality Improvement Activities" and updated language.

F. Federal Exclusion Screening Requirements ? Removed language from 1st bullet "For subcontractors, in addition to the forgoing, the definition of Exclusion Lists also includes". ? Added language to 2nd paragraph.

A. Introduction ? 7th paragraph - Removed "address" and replaced "addressed" with directed", and updated contact information.

B. Credentialing Application ? Added language to 1st bullet within the second set of bullets.

C. Credentialing Policies 1. Credentialing Process for Practitioner: (Medical and Behavioral Health) ? Specific requirements for specialties listed - updated bullets, language, (grammatical and formatting) as applicable. 2. Credentialing Process for Medical and Behavioral Health Organizational Providers ? Updated bullets, language, (grammatical and formatting) as applicable.

D. Practice Site/Medical Record Standards ? Added "approximately" to language within 5th paragraph. ? Added an asterisk to the Site Review Standards numbered list, where applicable. ? Medical Record Keeping Practices ? changed "should" to "must" in #1. ? Education and Preventive Care ? Updated language in #19.

E. Benefits Eligible Services 9. Behavioral Health. ? a. covered o Moved PA language from 1st paragraph to after the bulleted list. o Added an asterisk to indicate where the PA language was applicable within the list. o Added "medication" to bullet v. ? b. exclusions o Removed "telephone consultations" from bullet ix. language

G. Utilization Management ? Outpatient Services ? Updated link and language in last bullet. ? Equipment Providers ? Updated two broken links in 1st paragraph. ? Complex Rehab Technology - Added PA repair language and bullets.

B. TennCare Kids Screening Guidelines 2. Developmental, Emotional/Behav. & Elevated Blood Lead Level Screenings ? Updated broken link grid for Eyberg Child Behavior Inventory (ECBI)

Section # and Title

Affected Page(s)

Modification

XXII. CHOICES

421

435 440 442-443 443-444 446

447 448 453

461 462 462

? Updated Table of Contents E. Provider Roles and Responsibilities

3. Long-Term Services and Supports Providers ? Added "registries, and exclusion" to 7th bullet/language.

F. Provider Agreement Requirement ? Provider Nursing Facility additional requirements list ? Added numbered bullet 19 and language. ? CHOICES HCBS Provider additional requirements list - Added numbered bullets #16-18 with language. ? Added new language and numbered bullets list (#1-#18) for ICF/IID Provider additional requirements. ? Enabling Technology Providers/Vendors ? Added "registry, and exclusion" to 1st paragraph language.

G. Provider Contracting/Credentialing ? Updated list (#6) for Credentialing of LTSS Providers requirement documents. ? Added language to 6th paragraph. ? Claims Processing ? Added language for termination of contract due to change of ownership as 3rd paragraph.

K. General Information 1. Background Checks and Registry Checks ? Added "and Exclusion Checks" to end of the title. ? Updated language to reflect exclusion and/or registries, as necessary. 2. Reportable Event Management ? Updated language to 2nd paragraph for reporting timeline requirements for Tier 1 Reportable events and electronic form.

XIV. SelectCommunity Program

D. Nurse Care Manager

474

? Updated bullet language in 2nd set of bullets, as applicable.

Attachment I. NEMT Services

528, 544

? Removed Appendix C & D with language/links as they are no longer applicable. Therefore, Appendix E and F become C and D.

Attachment III. CHOW Policy

576

? Claims Reimbursement ? Added bullet to end of bulleted list

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Associat ion

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Provider Administration Manual

For ??BlueCare! T,ennCareSe/ect and Cove rKids Networks

&CiilBlueCare

T. 9. Tennessee

Effective January 1, 2024

BlueCare Tennessee Provider Administration Manual

Table of Contents

I.

Introduction

A. BlueCross BlueShield of Tennessee Statement of Purpose

B. Description of Health Plans and Health Plan Sub-Programs

1. BlueCare Tennessee operates two TennCare Program Health Plans:

C. General Information

1. Interpretation Services 2. Health Literacy and Cultural Competency Provider Tool Kit 3. Medical Referrals 4. Outpatient/Inpatient Behavioral Health Services 5. Prior Authorization 6. Protected Health Information-allowable disclosures under HIPAA 7. Fraud and Abuse 8. Reporting Requirements of BlueCare Tennessee

D. Appeals Quick Reference Guide E. Important Contact Information F. BCT Contract Quick Reference Guide G. Registering or Updating Your Provider Contract Address

II.

How to Identify a BlueCare Tennessee Member

A. Determining Eligibility

B. Member Liability

C. ID Card

D. BlueCare/TennCareSelect Provider Service Lines

E. Electronic Data Interchange (EDI)

III.

Primary Care Member Assignment

A. Primary Care Provider (PCP) Membership Listing

B. TennCareSelect Care Management Fee

C. Primary Care Provider (PCP) Changes

IV.

Benefits

A. Covered Benefits

1. Hospital Services (Inpatient) 2. Physician Services (Inpatient) 3. Physician Services/Community Health Clinic Services/Other Clinic Services (Outpatient) 4. Hospital Services (Outpatient) 5. Surgical/Medical Services 6. Inpatient Medical Services 7. Outpatient Medical Services 8. Ambulatory Surgical Treatment Center 9. Diagnostic Services 10. Newborn Services 11. Physical Services 12. Maternity Services 13. Reproductive Health Care and Family Planning Services 14. Preventive Services 15. TennCare Kids Services 16. Ambulance Services 17. Non-Emergency Medical Transportation Services (NEMT Services) 18. Behavioral Health Care Services 19. Private Duty Nursing Services 20. Home Health Care Services

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BlueCare Tennessee Provider Administration Manual

21. Prescription Drugs 22. Durable Medical Equipment (DME) 23. Phenylketonuria (PKU) Treatment 24. Prosthetic Appliances 25. Orthotic Devices 26. Therapy and Rehabilitation Services 27. Chiropractic Services 28. Hospice Services 29. Vision Services 30. Dental Services 31. TennCare for Prisoners Program

B. Benefit Exclusions

V.

Billing and Reimbursement

A. How to File a BlueCare Tennessee Claim

1. Filing Electronic Claims (Required Method) 2. Filing Paper Claims

B. Tips for Completing CMS-1500/CMS-1450 Claim Forms C. Timely Filing Guidelines D. Medicare/BlueCare Tennessee Dual Eligible Members E. Third Party Liability (TPL) F. General Billing and Reimbursement Information

1. Current Dental Terminology (CDT), Current Procedural Terminology (CPT?), Health Care Financing Administration Common Procedural Coding System (HCPCS) and International Classification of Diseases (ICD) Coding

2. Addition/Deletion/Revision CDT Codes 3. Addition/Deletion/Revision CPT? Codes 4. Addition/Deletion/Revision HCPCS Codes 5. Addition/Deletion/Revision ICD Codes 6. Unlisted, Miscellaneous, Non-Specific, and Not Otherwise Classified (NOC)

Procedures/Services 7. Self-Administered Medications 8. Final Reimbursement 9. Faxed, Photocopied and Altered Claims 10. Policy for Quarterly Reimbursement Changes 11. Policy for Codes Priced on an Individual Consideration Basis 12. Quest Diagnostics Laboratory Billing Guidelines 13. BCT Laboratory Testing Code Reimbursement Policy 14. Telehealth Originating Site Fees and Billing Guidelines 15. Non-Standard Billing Requirement 16. Emergency/Non-emergency 17. Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) 18. Division of TennCare Budget Memo Guidelines 19. Claim Billing Requirements for 340B Drug Pricing Providers 20. Real Time Claim Adjudication

G. CMS-1500 Health Insurance Claim Form

1. Sample Copy CMS-1500 (02/12) version claim form 2. CMS-1500 (02/12) Claim Form Block Descriptions: 3. Data Elements Required for Submitting CMS-1500 Claims

H. Completing CMS-1500 Claim Form

1. General Instructions 2. Physical Claim Form Specifications

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BlueCare Tennessee Provider Administration Manual

3. Form Contents and Description

I. Specific CMS-1500 Claim Form Billing and Reimbursement Guidelines

1. Anesthesia Billing and Reimbursement Guidelines 2. Obstetric Anesthesia 3. Reimbursement Guidelines for Administration of Regional or General Anesthesia

Provided by a Surgeon 4. Reimbursement Policy for Moderate Conscious Sedation 5. OB/GYN Services 6. Reimbursement Guidelines for Bundled Services Regardless of the Location of Service 7. Reimbursement Guidelines for Bundled Services when the Location of Service is the

Practitioner's Office 8. Professional and Technical Components for Radiology, Laboratory and Other Diagnostic

Procedures 9. Reimbursement Guidelines for Multiple Procedures 10. Reimbursement Guidelines for Bilateral Procedures 11. Assistant-at-Surgery Billing Guidelines and Reimbursement Policy 12. Reimbursement Guidelines for Procedures Performed by Two Surgeons 13. Reimbursement Guidelines for Procedures Performed on Infants Less than 4kg 14. Reimbursement Guidelines for Unusual Procedural Services 15. Reimbursement Guidelines for Screening Test for Visual Acuity 16. Reimbursement Guidelines for Visual Function Screening 17. Reimbursement Guidelines for STAT Services 18. Reimbursement Guidelines for Online Evaluation and Management Services 19. New Patient Replacement Edit for Evaluation and Management Services 20. Billing Guidelines and Documentation Requirements for CPT? Code 99211 21. Reimbursement Guidelines for Measurement Reporting Codes 22. Modifiers Requiring Special Handling 23. Medically Unlikely Edits (MUEs) 24. TennCare Kids Services 25. Injections and Immunizations 26. Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) 27. Transportation 28. Newborns (Applies to CoverKids effective DOS 1/1/2021) 29. Medication Therapy Management Program 30. Reimbursement Policy for CPT? Category III Codes

J. Staff Supervision ? Requirements for Delegated Services K. Locum Tenens Policy L. CMS-1450 Facility Claim Form M. CMS-1450 Claim-Specific Billing and Reimbursement Requirements

1. Hospital Inpatient Acute Care: 2. Post-Partum Voluntary Long Acting Reversible Contraceptive Reimbursement (PP

VLARC) 3. Neonatal Services Reimbursement 4. Policy for Present On Admission (POA) Indicators 5. Reimbursement Policy for Selected Hospital Acquired Conditions (HACs) Not Present on

Admission (POA) 6. Reimbursement Policy for Serious Reportable Adverse Events (Never Events) 7. BlueCross BlueShield of Tennessee (BCBST)/BlueCare Tennessee (BCT) Facility Fee

Schedule Reimbursement Methodology Policy 8. Hospital Outpatient 9. Hospital Outpatient/Ambulatory Surgery 10. CPT? Code with Surgery Revenue Code 11. Observation Room 12. Newborn (Applies to CoverKids effective DOS 1/1/2021)

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