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
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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
6
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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