Provider Communications Administration Manual
BlueCross BlueShield of Tennessee Provider Administration Manual
I. INTRODUCTION A. Our Statement of Purpose B. Descriptions of Networks C. Individual Product and Plan Options D. Health Insurance Portability and Accountability Act of 1996 E. General Information
II. BLUECROSS BLUESHIELD OF TENNESSEE QUICK REFERENCE GUIDES A. BCBST Telephone Quick Reference Guide B. BCBST Contract Quick Reference Guide C. Registering or Updating Your Provider Contract Address
III. HOW TO IDENTIFY A BLUECROSS BLUESHIELD MEMBER A. Identifying a Member's ID Card B. Determining Eligibility C. Member Fees
IV. GROUP HEALTH CARE BENEFITS A. Eligible Providers of Service B. Additional Services C. General Exclusions from Coverage
V. MEMBER POLICY A. Introduction B. Member Access-to-Care C. Member Rights and Responsibilities D. Member Grievance Process E. Financial Responsibility for the Cost of Services
VI. BILLING AND REIMBURSEMENT A. How to File a Claim 1. Filing Electronic Claims (Required Method) 2. Filing Paper Claims 3. Tips for Completing CMS-1500 and CMS-1450 Claim Forms 4. CMS-1500 Health Insurance Claim Form 5. Completing CMS-1500 Claim Form 6. Staff Supervision Requirements for Delegated Services 7. Locum Tenens Policy 8. CMS-1450 Facility Claim Form 9. Instructions for Returned Claims and Processed Claims Needing Correction 10. Coordination of Benefits 11. Maintenance of Benefits 12. Right of Reimbursement and Recovery (Subrogation) 13. Balance Billing 14. Provider Overpayment Recovery Policy/Process 15. Electronic Funds Transfer 16. Federal Employee Program (FEP) Claims Filing Guidelines
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BlueCross BlueShield of Tennessee Provider Administration Manual
B. General Billing and Reimbursement Guidelines
1. Medical Clinical Code Sets and Maintenance 2. Miscellaneous, Non-Specific and Not Otherwise Classified (NOC)
Procedures/Services (Refer to "How to File a Claim" in this section for billing information) 3. Code Edits 4. Modifiers 5. Real Time Claim Adjudication 6. Qualitative Drug Screen Testing 7. Reimbursement Policy for Serious Reportable Adverse Events (Never Events) 8. Final Reimbursement 9. Policy for Quarterly Reimbursement Changes 10. Policy for Codes Priced on an Individual Consideration Basis
C. Professional Claim Billing and Reimbursement Guidelines
1. Lesser Of Calculation 2. Split Bills 3. Reimbursement Hierarchy for Professional and Home Health Services 4. Anesthesia Billing and Reimbursement Guidelines (Medicare lines of
business will follow CMS guidelines) 5. Obstetric Anesthesia 6. Reimbursement Guidelines for Administration of Regional or General
Anesthesia Provided by a Surgeon 7. Reimbursement Policy for Moderate Conscious Sedation 8. Guidelines for Resource Based Relative Value Scale (RBRVS)
Reimbursement Methodology 9. Status Indicators 10. PC/TC Indicator ? Global, Professional and Technical Components for
Radiology, Lab and Other Diagnostic Procedures 11. BCBST Laboratory Testing Code Reimbursement Policy 12. Global Days ? Reimbursement Guidelines for Global Periods 13. Preoperative, Intraoperative, and Postoperative ? Reimbursement
Guidelines for Preoperative Management Only, Surgical Care Only, and Postoperative Management Only Services (Modifiers 54, 55 56) 14. Reimbursement Guidelines for Multiple Procedures Using Modifier 51 (Medicare lines of business will follow CMS guidelines) 15. Reimbursement Guidelines for Bilateral Procedures 16. Assistant-at-Surgery (Modifiers 80, 81, 82, AS) 17. Reimbursement Guidelines for Procedures Performed by Two Surgeons (Modifier 62) 18. Reimbursement Guidelines for Screening Test for Visual Acuity 19. Reimbursement Guidelines for Visual Function Screening 20. Obstetrician-Gynecologist Services 21. Reimbursement Guidelines for Independent Lab Services 22. Reimbursement Guidelines for STAT Services
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BlueCross BlueShield of Tennessee Provider Administration Manual
23. Reimbursement Guidelines for Online Evaluation and Management (E&M) and New Technology Services
24. Guidelines for Evaluation and Management (E&M) New or Established Patient Determinations
25. Billing Guidelines and Documentation Requirements for CPT? Code 99211
26. Genetic Counseling Services Billing Guidelines 27. Lactation Consultant Services Billing Guidelines 28. Chiropractor Billing and Reimbursement Guidelines (Doesn't apply to
MedAdvantage or the Federal Employee Program (FEP)). 29. Acupuncture Billing and Reimbursement Guidelines (Doesn't apply to
MedAdvantage 30. Injections and Immunizations 31. Home Infusion Therapy (HIT) 32. Durable Medical Equipment, Prosthetics, Orthotics and Medical
Supplies (DMEPOS) 33. Telehealth Originating Site Fees and Billing Guidelines 34. Air Ambulance Services 35. Allergy Immunotherapy ? CPT? Code 95165
D. Institutional Claim Billing and Reimbursement Guidelines ? Section 1
1. Revenue Codes (CMS-1450) 2. Split and Interim Billing 3. Electronic Billing Instruction 4. Explanation Codes 5. Adjusted Claims 6. Late Charges 7. Member Liability 8. Lesser-Of Calculation 9. Non-Standard Billing Requirement 10. Acute Care Facilities ? Inpatient 11. Acute Care Outpatient Services 12. Acute Care All-Inclusive Rates 13. Acute Care Fee Schedules 14. Other Acute Care Outpatient Services 15. All Other Outpatient Services 16. Other Acute Care Exclusions 17. Other Institutional Facility Types
E. Institutional Claim Billing and Reimbursement Guidelines ? Section 2
1. Outpatient Surgery 2. Minor Surgery 3. Acute Care Fee Schedules 4. Acute Care ER Services 5. Intravenous (IV) Therapy Services 6. Reimbursement Policy and Billing Guidelines for the Separately
Reimbursed Facility Drug Fee Schedule
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BlueCross BlueShield of Tennessee Provider Administration Manual
7. Observation Services 8. MRI/MRA/CT Scan 9. All Other Outpatient Services: VII. UTILIZATION MANAGEMENT PROGRAM
A. Program Overview B. Medical Review C. Medical Review Requirements
1. Inpatient Admission 2. Emergency Admission 3. Observation Stays 4. Non-Compliance 5. Maternity, Labor and Delivery, Newborn 6. Home Health Services/Skilled Nursing Visits 7. Transitional Care/Discharge Planning 8. Cosmetic Surgery 9. Out-of-Network Services 10. Transplant Services 11. Hospice Services 12. Ambulatory Surgeries (Appropriateness Review), Diagnostic and Other
Procedures 13. Specialty Pharmacy Medications 14. Home Infusion Therapy 15. Rehabilitation Therapy Outpatient Services 16. Medical Supplies (Outpatient Rehabilitation Services) 17. Durable Medical Equipment 18. Advanced Imaging/High-Tech Imaging 19. Musculoskeletal (MSK) Management 20. Neonatal Intensive care (NICU)/Special Care Nursery (SCN) through
First-Year Care Management 21. Performance Evaluations of Delegate Vendors and Providers 22. Second Surgical Opinion 23. Non-Emergent Air Ambulance Transportation 24. Molecular and Genomic Testing 25. Radiation Oncology 26. Lab Sleep Studies
D. Emergency Services E. Investigational Services F. Clinical Trials G. Medically Necessary and Medically Appropriate Policy H. Prospective and Retrospective Review I. Provider Appeal Process J. Medical Policy Manual K. Transparency L. Directing Members to Participating Providers in Members' Network M. Utilization Management Resources
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