Member Provider Policy & Procedure Manual

Member Provider Policy & Procedure

Manual

18NW1073 R12/16

providers ilinkblue

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

Blue Cross and Blue Shield of Louisiana

MEMBER PROVIDER (FACILITY) POLICY & PROCEDURE MANUAL

This manual is designed to provide information you will need as a participant in the Blue Cross and Blue Shield of Louisiana Member Provider Network--it is an extension of your Member Provider Agreement.

To use your manual, first familiarize yourself with the Network Overview and Definitions sections. From that point on, the Table of Contents should direct you to the information you need.

Periodically, we send newsletters and informational notices to providers. Please keep this information and a copy of your respective provider agreement(s) along with your manual for your reference. Updated office manuals and provider newsletters may be found on the Provider page of our website at providers.

If you have questions about the information in your manual or your participation as a Member Hospital, please call Network Administration at 1-800-716-2299, option 3 or (225) 297-2758.

Please note: This manual contains a general description of Benefits that are available subject to the terms of a Member's contract and our corporate medical policies. The Member Contract/Certificate contains information on Benefits, limitations and exclusions and managed care benefit requirements. It also may limit the number of days, visits or dollar amounts to be reimbursed. This manual is provided for informational purposes and is an extension of your Member Provider Agreement. Every effort has been made to print accurate, current information. Errors or omissions, if any, are inadvertent.

As stated in your agreement: This manual is intended to set forth in detail Blue Cross policies. Blue Cross retains the right to add to, delete from and otherwise modify the Member Provider Policy & Procedure Manual as needed. The Member Provider Policy & Procedure Manual and other information and materials provided by Blue Cross are proprietary and confidential and may constitute trade secrets of Blue Cross.

CPT only copyright 2017 American Medical Association. All rights reserved. ICD-10 2017 ? 2017 Ingenix, Inc.

HCPCS 2017 ? 2017 Practice Management Information Corporation

Website/Email Call/Fax

87 '7

Mail

,

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company.

P.O. Box 98029, Baton Rouge, Louisiana 70898-9029 ? 1-800-716-2299

Member Provider Policy and Procedure Manual

TABLE OF CONTENTS

Quick Reference Guide to Important Addresses and Phone Numbers

8

Section 1: Network Participation

9

Participating Provider Agreements

9

Amendments to Provider Agreements

10

Member Provider Benefits

10

Allied Health Providers

11

Non-participating Providers

11

Credentialing Program

12

Credentialing Requirements for Freestanding Diagnostic Imaging Facilities

14

Locum Tenens 15

Medical Staff

15

Urgent Care Center Hours of Operation

15

Provider Directories

15

Health Care Consumer Billing and Disclosure Act

17

Section 2: Network Overview

18

Network Overviews

18

BlueCard? Program

24

Consumer Directed Health Care

28

HMO of Louisiana Inc.'s Blue Advantage (HMO) Plan

31

Medicare Advantage Members from Other Blue Plans

31

Section 3: Member Engagement Tools

32

Section 4: Inpatient Acute Care Reimbursement

34

Overview

34

Charge Master Increase 35

Subcontracted Providers 36

Medical Staff 36

General Information

36

Diagnosis Code Specificity

37

Commercial Risk Adjustment

38

Payment Methodology Examples

38

MS-DRG Outlier Payment Examples

42

Payment Provision Worksheet (Per Diem)

43

Inpatient Billing Guidelines

44

Section 5: Outpatient Acute Care Reimbursement

47

Overview

47

Outpatient Procedure Services

47

Charge Master Increase

49

Billing Guidelines 50

Outpatient Procedure Services

50

Diagnostic and Theraputic Services

51

Drug Allowable Charge

53

Drug Screening Assays 53

Billing of Drug Eluting Intracoronary Stint

54

Other Outpatient Services

54

Outpatient Code Updates

54

Service Exempt from the Multiple Procedure Discount

55

Multiple Service Reduction for Diagnostic Imaging Services

56

Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures Manual

December 2016 5

New Codes

56

Not Seperately Reimbursable Codes

57

Observation

57

Emergency Room

57

Pricing Flowchart for Outpatient Acute Care Reimbursement

58

Section 6: Additional Reimbursement Information

59

Other Facility Reimbursement Programs

59

Physician Reimbursement

59

Section 7: Claims Submission & Payment

61

Important Rules for All Claims Submissions

61

Overpayments

62

Federal Employee Program (FEP) Non-Network Claims-Direction of Payment

62

Claims Re-submission (Re-filing)

62

Adjustment and Void Claim Submission

62

Diagnosis/Procedure Coding

64

Procedure Codes and Guidelines -Professional & Certain Outpatient Services

65

Modifiers

65

Provider Access to iLinkBlue Medical Coding Section

67

Serious Preventable Events and Present on Admission Indicators

67

National Provider Identifier (NPI)

71

Tax ID Numbers (TIN)

73

Reporting National Drug Code (NDC) on Claims

73

Coordination of Benefits

74

Subrogation

74

Employment-related Injuries or Illness

75

Medicare Supplemental Claims

76

Nonparticipating Member Provider Benefits Payment Policy

78

Timely Filing and Refunds Process

79

Member Refunds

79

UB-04 Claim Form

80

CMS-1500 Health Insurance Claim Form

86

iLinkBlue 1500 Claim Electronic Entry Screen

92

Example Payment Register/Remittance Advice

97

Payment Register/Remittance Advice Explanation

98

Section 7A: Electronic Claims Submission & Payment

99

Electronic Data Interchange (EDI)

99

iLinkBlue Provider Suite

99

Electronic Payment Register/Remittance Advice

100

Electronic Funds Transfer (EFT)

101

EFT Application Guide

102

EFT Application Form

105

Section 8: Billing Guidelines

107

Ambulance

108

Anesthesia

115

Behavioral Health

124

Chiropractic and Therapy Services

134

Delivery of Pregnancy

138

Dialysis

140

Dietitian Billing Guidelines

141

Laboratory - Using Preferred Reference Labs

143

Sleep Study

147

Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures Manual December 2016

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Home Sleep Study Services for Obstructive Sleep Apnea (OSA)

149

Home Health

150

Section 9: Federal Employee Program

154

Standard Option

154

Basic Option

154

Cancer Screening

155

Provider Tips

155

Section 10: Provider Audits

156

Section 11: Medical Management

157

Overview

157

Utilization Review Organization

157

Authorization Process

157

Concurrent Review

159

Case Management

160

Retrospective Review

160

Medical Policy Inquiry

161

Direct Access

162

Services That Requiring Authorization Prior to Rendering Services

163

OGB Plan Services Requiring Authorization

164

Authorization for High-Tech Imaging Services

165

Authorization Penalties for Providers

166

Drug Authorizations

167

Quality Management Program

167

Step Therapy Program

168

Maternity Management Program - Healthy Blue Beginnings

169

Explanation of Admission and Recertification Request Form

170

Admission and Recertification Request Form

171

Section 12: Medical Appeals

173

Standard Administrative Appeal

174

Standard Medical Appeal

175

Expedited Internal Medical Appeal

176

Expedited External Medical Appeal 177

Section 13: General Dispute Resolution & Arbitration Process

179

Section 14: MS-DRG Type of Service Listing

181

Section 15: Communicating with Blue Cross

196

Electronic Benefit Verification

196

Provider Services Voice Response Telephone System Call Center

196

Customer Service

197

Preadmission Authorization

197

Provider Network Administration

198

Provider Relations Services

198

Section 16: Definitions

199

Summary of Changes

209

Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures Manual

December 2016 7

Quick Reference Guide to

IMPORTANT ADDRESSES AND PHONE NUMBERS

' Provider Services Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. offer an enhanced Interactive Voice Response (IVR) system that lets you and your office staff take care of many routine services by phone 24 hours a day, seven days a week. Call the customer service phone number on the back of your patient's Blue Cross ID card and enter your NPI number and the patient's member number when prompted and select one of the following options: ? Benefits - Voice back of benefits - Fax back of benefits ? Claims - Voice back of claims status - Fax back of claims status ? Medical Management* - Status of authorization - Request new authorization

*Medical Management requests are handled by transfer; not currently by self-service.

Provider Network Administration

, network.administration@ Participation/Contracting/Credentialing/Provider Relations Questions: 1-800-716-2299 or (225) 297-2758. Claims Addresses All completed claim forms should be forwarded to the following addresses for processing:

Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029

FEP claims should be mailed to: Blue Cross and Blue Shield of Louisiana - FEP Claims P.O. Box 98028 Baton Rouge, LA 70809-9029

8

Electronic Services

ilinkblue iLinkBlue.ProviderInfo@ 1-800-216-BLUE (1-800-216-2583)

EDI Clearinghouse EDICH@ (225) 291-4334

BlueCard? Eligibility Line

1-800-676-BLUE (1-800-676-2583)

Member Benefits

Call the number on the member's ID card.

Fraud & Abuse Hotline

1-800-392-9249

Appeals and Grievances/Provider Dispute Resolution

Blue Cross and Blue Shield of Louisiana Appeals and Grievance Department P.O. Box 98045 Baton Rouge, LA 70898-9045

1-800-376-7741

Blue Cross and Blue Shield of Louisiana Member Provider Policy & Procedures Manual December 2016

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