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Regular BusinessBlueCard 2009 Medicare Advantage PPO Network SharingBeginning January 1, 2009, BCBS Medicare Advantage(MA) PPO network sharing will be available in the CMSapproved MA PPO local service areas for the followingBlue Cross and/or Blue Shield Plans: Healthnow (BlueCross BlueShield of Western New Yorkand BlueShield of Northeastern New York) Blue Cross and Blue Shield of South Carolina BlueCross BlueShield of Tennessee.Network sharing will allow MA PPO members from theseBlue Plans to obtain in-network benefits when travelingor living in the service areas of the other two Plans aslong as the member sees one of those Plans’ contractedMedicare Advantage PPO providers.There is no change to your current billing procedures.You should continue to verify eligibility and bill forservices as you currently do for any out-of-area BlueMedicare Advantage member. Benefits are based onthe Medicare allowed amount for covered services andpaid under the member’s out-of-network benefits, unlessservices are for urgent or emergency care. Once yousubmit the MA claim, BCBSMT will send you payment.The “MA” in the suitcase on the member’s ID cardindicates a member who is covered under the networksharing program (figure 1). Remember, this only affectsproviders of Plans in the MA PPO network sharingprogram in 2009. Members have been asked not toshow their standard Medicare ID card when receivingservices. Instead, members should provide their BlueCross and/or Blue Shield member ID.You may see these and other out-of-area Blue MedicareAdvantage members, but you are not required toprovide services. Should you decide to provide servicesto any Blue Medicare Advantage out-of-area members,you will be compensated for covered services at theMedicare allowed amount based on where the serviceswere rendered and under the member’s out-of-networkbenefits. For Urgent or Emergency care, you will becompensated at the in-network benefit level.If you choose to provide services to a Blue Private-Feefor-Service (PFFS) member (as a “deemed” provider),you will be compensated for covered services at theMedicare allowed amount as outlined in the Plan’s PFFSTerms and Conditions.Call BlueCard Eligibility at 1.800.676.BLUE (2583) andprovide the member’s alpha prefix located on the IDcard. You may also log onto www.bcbsmt.com andverify eligibility when you register for online serviceswith BCBSMT. Out-of-area claims, benefits, andeligibility are available through BlueExchange.Submit the claim to BCBSMT, and do not bill Medicarefor services rendered to a Medicare Advantage member.Benefits are based on the Medicare allowed amountfor providing covered services to any Blue MedicareAdvantage out-of-area members.Any MA PPO members from out-of-area will pay theout-of-network cost sharing amount. You may collectthe co-payment amounts from the member at the timeof service. Once the member receives care, you shouldnot ask for full payment up front other than out-of-pocketexpenses (deductible, co-payment, coinsurance, andnon-covered services).Under certain circumstances when the member has beennotified in advance that a service will not be covered,you may request payment from the member beforeservices are rendered or billed to the member. Themember should sign an Advance Member Notificationform before services are rendered in these situations.These forms are available at www.bcbsmt.com underPrior Authorization.figure 1[ Fourth Quarter 2008 ] CapsuleNews5

Regular BusinessIf you have questions, call your Provider Network Servicerepresentatives at 1-800-447-7828, Extension 3600 oremail questions to HCS-X3600@bcbsmt.com.Electronic ID CardsSome Blue Cross and/or Blue Shield Plans around thecountry have implemented electronic ID cards to helpmembers easily verify coverage and eligibility. BCBSMThas not implemented electronic ID cards, but membersfrom other Blue Plans reside in Montana and may havethis new technology.A BCBS electronic health ID card has a magnetic stripeon the back of the ID card, similar to what you find onthe back of a credit or debit card. The member’s datais embedded in the third track of the 3-track magneticstripe and includes the member’s name, health plan ID,date of birth, and Plan ID. Electronic health ID cardscan also transfer member data to the provider’s practicemanagement system.Providers need a Track 3 card reader for the data to beread. The majority of card readers in provider officesonly read Tracks 1 and 2 of the magnetic stripe, which areproprietary to the financial industry.A sample of electronic health ID card is shown below.TriCare/TriWestSubmitting Electronic Claims when Other Health Insuranceis PrimarySecondary and tertiary West Region claims can besubmitted electronically through your clearinghouse orat www.triwest.com. The other health insurance (OHI)explanation of benefits must be included along with theprimary payer allowed amount, paid amount, and theOHI Payment Reason code.For 837P or 837I transactions, be sure to include theprimary payer amount allowed, paid amount, and if priorpayment has not been made, the primary payer reasoncode. TRICARE follows the ASC X12 837 implementationguides for claims processing. The following providessome of the basic 837 requirements for secondary andtertiary claims processing: Other Subscriber Information: The 2320 loop isrequired when reporting other insurance, prior orotherwise. AMT Prior Payer Paid: This information is required ifclaim has been previously processed by another payer. AMT (Allowed Amount): Allowed amounts arereported in the AMT field. However, if the AMT cannotbe reported, the Claim Level Adjustments segment isnecessary to process the claim. OI (Other Insurance): Other coverage information isrequired if the 2320 loop is present.TriWest pays claims with OHI line-by-line. The TRICAREEOBs list the member responsibility, and if it is ‘0’, themember cannot be billed.To submit line level OHI information, refer to theWPS 837 Companion Guide published in the Your EDIConnection area at www.triwest.com/provider.TriWest Interactive Voice Response System UpdatesProviders who call 1-888-TRIWEST (1-888-874-9378)now have the ability to verify eligibility and otherinformation over the phone. The new functionality givesyou the opportunity to obtain the member informationyou need without the assistance of a customer servicerepresentative.[ Fourth Quarter 2008 ] CapsuleNews6

Regular BusinessGetting to the main menu is still the same. However,once you select Eligibility, simple prompts guide youto the self-service menu. From the eligibility menu,you will be asked whether your call is about medical orbehavioral benefits. Behavioral health calls are sent tothe Behavioral Health Department. If you are seekingmedical benefits, you will be asked for your tax IDnumber.Behavioral Health Continuing EducationPreviously, providers were only given the name of theplan in which the patient was currently enrolled. Thenew service gives you the effective date of coverage, andyou also have the opportunity to obtain:Providers who complete the course will receive twocontact-hours of Continuing Education Unit (CEU)credits. The University of North Texas Health ScienceCenter at Fort Worth is accredited by the AmericanOsteopathic Association to award continuing medicaleducation to physicians. Copayments Deductibles (for the plan and amount met to date) Cost-sharing amounts Point-of-service information Maximum out-of-pocket expenses (catastrophic cap)for the plan and amount met to date Other health insurance information such as the type ofplan, plan primacy, and pharmacy coverageYou will also have the option to have the informationfaxed to your office. Customer service representativesare still available to provide assistance.Additional information, including an IVR tip sheet, isavailable at www.triwest.com/provider.In cooperation with the University of North Texas (UNT)Health Science Center at Fort Worth, TriWest is offering afree online course for providers to better help TRICAREmembers deal with post-deployment behavioral healthissues. The course will provide education to you identifyand treat post-combat mood and anxiety disorders.The faculty consists of VADM (ret.) Harold M. Koenig,M.D., former Surgeon General of the Navy President andChairman of the Board, The Annapolis Center for ScienceBased Public Policy and LTC Michael J. Roy, M.D., M.P.H.,Professor of Medicine, Uniformed Services University ofHealth Sciences.The content is a streaming video of a live posttraumaticstress disorder seminar with an interface that displaysthe video and tracks the viewer’s progress. Providersneed to watch all videos before they can access theonline evaluation and credit request form. A link to thevideo and CEU information can be found at www.triwest.com/provider in the Stay Updated section under theContinuing Education link.If you have questions about TRICARE benefits, resources,or need more information, log onto www.triwest.com orcontact the TriWest Healthcare Alliance at 1-888-TRIWEST(1-888-874-9378).[ Fourth Quarter 2008 ] CapsuleNews7

Regular BusinessOther BusinessCHIP Extended Mental Health Benefits Claims ProcessingEffective October 1, 2008, BCBSMT will process claimsfor the CHIP Extended Mental Health Plan for Childrenwith a serious emotional disturbance (SED). However,there is one exception. Community Based PsychiatricRehabilitation and Support (reported with HCPCSCode H2019) will continue to process through AffiliatedComputer Services (ACS). All Extended Mental Healthclaims with dates of service before October 1, 2008, willcontinue to process through ACS.This change was made so that most of the CHIPmental health benefits process under the same claimsprocessing contractor. This change also addressesprovider concerns about simplified claims processing forCHIP Extended Mental Health benefits.The process to determine whether a child is eligible forCHIP Extended Mental Health Benefits has not changed.To qualify, the child must be enrolled in CHIP and meetSED criteria. Updated clinical assessment guidelines arepublished on the CHIP website at www.chip.mt.gov. Alsoincluded are the Extended Mental Health Plan fact sheetand benefit table.For more information, call the CHIP Extended MentalHealth Specialist at 1-877-KIDS NOW (543-7669),Extension 0946.Electronic Coordination of Benefits Now AvailableBCBSMT upgraded its claims processing system toallow coordination of benefits’ (COB) (secondary) claimsto be submitted electronically. The system upgradewas completed September 12, 2008, and professionalproviders that submit electronic CMS-1500 claims nolonger have to print and submit COB claims by mail. Thisdoes not include facility claims (UB92).When submitting electronic COB claims, refer to yoursoftware vendor’s billing instructions and complete allrequired COB information. COB information shouldbe sent at the line-level and not at the claim-level. Inaddition to the required COB information, you mustsubmit the other carrier allowed information and paidamount and all claim-level adjustment group codes,reason codes, and payment amounts.It is very important to use the appropriate Insurance Typecode in the correct loop and segment in the 837 file (loop2320 and segment SBR05). Your software will most likelyhave a field labeled Insurance Type, or you may have adrop down box from which you can choose the correctInsurance Type code. Your vendor will be able to help youif you are unsure about where to find this field.The table below lists all Insurance Type codes:CodeDescriptionAPAuto Insurance PolicyC1Commercial PolicyCPMedicare Conditionally PrimaryGPGroup PolicyHMHealth Maintenance Organization (HMO)IPIndividual PolicyLDLong Term PolicyLTLitigationMBMedicare Part BMCMedicaidMIMedigap Part BMPMedicare PrimaryOTOtherPPPersonal Payment (Cash- No Insurance)SPSupplemental PolicyIt is also important to enter the primary memberinformation correctly. If the claim is not an Ex12 claim,you must add, reimport, or move the member from holdor archive status. The table below provides the steps toenter the primary member information.StepAction1Select ANSI 837P or ANSI 837I/List of Claims2Click on the Patient Name to Edit3Select Auxiliary Info Tab4Under Subscriber Information Section, select PrimarySubscriber link5Add the Adjudication Date in the Patient InformationBox (The Primary Subscriber Information will bedisplayed)Make sure your screen has the following fieldscompleted:FieldEnter or Select the PrimarySubscriber Type1 PersonNameInsured’s last name and first nameBirth DateInsured’s date of birthPatient RelationshipInsured relationship to patientGenderInsured’s gender[ Fourth Quarter 2008 ] CapsuleNews8

Regular BusinessAddressInsured’s addressInsurance PolicyInsured’s policy number “optional”Compensation MethodSocial SecurityNumberSocial Security Number “optional”Anesthesia Non-Fac PricingPayer NamePrimary Payer Name (not a Medigap payer)Compensation is based on thehigher nonfacility RVU valueregardless of the place ofservice.Subscriber IDInsurance policy/subscriber id numberBased on BenefitAssign BenefitsY or NCompensation is based on themember’s benefits.Payer IDPayer ID NumberBlank NUNoridian AdministrativeServices DMEPOS fee schedulepublishes an NU amount.Compensation is the sameregardless of modifier NU.Clinical Lab - CoreThe core group is compensatedat 160% of the CMS clinicallaboratory fee schedule.Clinical Lab - SecondaryThe secondary group iscompensated at 150% of theCMS clinical laboratory feeschedule.CMS RVUCompensation is based onthe CMS RBRVS system forevaluation and management,medicine, surgery, pathology,machine test, and radiologycodes.Home Infusion TherapyCompensation is based onprovider network agreement.Invalid HCPCS-BCBSMTCPT Category II performancemeasurements, HCPCSdemonstration project codes,HCPCS rehabilitative “h” codes,and Medicaid “T” codes are notvalid BCBSMT codes. T0124and T0125 are allowed forDPHHS.Local Carrier DME PricingCompensation is the same asthe CMS Reasonable ChargeFee Schedule.BCBSMT Calculated PriceCompensation is determinedbased on comparison to similarprocedures, invoice chargesless shipping and handling, andsupplier price lists.NU Calc from RRCompensation is based onthe Noridian AdministrativeServices DMEPOS fee schedulefor the NU modifier. Theamount is divided by 12 todetermine the RR price.Region D DMERCNoridian AdministrativeServices DMEPOS fee schedule.If you have questions, call Health-e-Web at 877-565-5457or submit a question online at www.hewedi.com.BCBSMT Provider Manual UpdatedThe BCBSMT Provider Manual has been updatedand published at www.bcbsmt.com. The manual iscontinually reviewed for clarity and style with the goalof providing simple and direct instructions. A summaryof material changes made in the third quarter of 2008includes:1. Updated the products excluded from the BlueCardProgram (6-1).2. Updated BlueCard international member informationwith instructions for BCBS Canada members (6-4).If you have suggestions for improvement or content,contact your Provider Network Service Representativesat hcs-x3600@bcbsmt.com or at 1-800-447-7828,Extension 3600.CHIP Prior Authorization Forms Available OnlineThere are two new CHIP prior authorization formsavailable at www.bcbsmt.com (Click on Providers andthen Prior Authorization). Services with recommendedprior authorization are listed along with the forms.One form is specific to hearing aid benefits and is usedfor audiologists to prior authorize hearing aids andrelated supplies. Hearing aid suppliers should completethis form to prior authorize batteries, repair, and cleaningof hearing aids.If you have questions, call your provider relationsrepresentatives at 1-800-447-7828, Extension 3600, orsend an email to HCS-X3600@bcbsmt.com.Fee Schedule Compensation DescriptionBCBSMT updated its fee schedules to include a legendexplaining the Compensation Method column for eachfee schedule. BCBSMT publishes its CPT, HCPCS,and drug fee schedules at www.bcbsmt.com (Clickon Providers and then Fee Schedules). If you havequestions, call your provider relations representativesat 1-800-447-7828, Extension 3600, or send an email toHCS-X3600@bcbsmt.com.Description[ Fourth Quarter 2008 ] CapsuleNews9

Regular BusinessRR Calc from NUST Anthony RVUCompensation is based onthe Noridian AdministrativeServices DMEPOS fee scheduleamount for the RR modifier.The amount is multiplied by 12to determine the NU price.Compensation is based on St.Anthony’s/Ingenix EssentialRBRVS for evaluation andmanagement, medicine,surgery, pathology, machinetest, and radiology codeswithout a CMS RVU.Place of Service CodesThe BCBSMT Claims Department is seeing a largenumber of claims billed with the wrong place of service.This is a reminder that the correct place of service iscritical to accurate and timely claims processing. Thetable below lists the place of service codes.CMS1500POSPlace of Service01Pharmacy03School04Homeless Shelter05Indian Health Service Free-Standing Facility06Indian Health Service Provider Based FacilityMedicareBlue PPO07Tribal 638 Free-Standing FacilityClinical Practice Guidelines Available Online08Tribal 638 Provider-Based FacilityOn May 16, 2006, the Regional Quality ImprovementCommittee approved the implementation of the Institutefor Clinical Systems Improvement Clinical PracticeGuidelines for the MedicareBlue PPO plan administeredby the BCBS Northern Plains Alliance. The guidelineswere developed using an evidence-based approach,which emphasizes the critical evaluation of scientificevidence, rather than expert opinion or consensus.11Office Visit12Home13Assisted Living Facility14Group Home15Mobile Unit20Urgent Care Facility21Inpatient HospitalThe guidelines are published online at www.yourmedicaresolutions.com (click For Providers). If youdo not have Internet access and require a printed copy,contact Kris Thompson at 406-444-8905.22Outpatient Hospital23Emergency Room24Ambulatory Surgical Center25Birthing CenterModifier Use When Coding Claims Policy26Military Treatment Facility31Skilled Nursing Facility32Nursing Facility33Custodial Care Facility34Hospice41Ambulance- LandThe policy includes all modifiers affecting BCBSMTclaims processing and/or compensation and indicateswhether records or medical notes are required.Also included is information about ambulance andinformational modifiers.42Ambulance- Air or Water49Independent Clinic50Federally Qualified Health Center51Inpatient Psychiatric Facility52Psychiatric Facility Partial HospitalizationThe Modifier Use When Coding Claims Policy ispublished at www.bcbsmt.com (Click on Providers andthen Provider Policies). If you have questions or needcontracts and credentialing applications, contact yourProvider Network Service Representatives at HCSX3600@bcbsmt.com or at 1-800-447-7828, Extension3600.53Community Mental Health Center54Intermediate Care / Mentally Retarded55Residential Substance Abuse Treatment56Psychiatric Residential Treatment57Non-residential Substance Abuse Treatment Facility60Mass Immunization CenterSuspendServices suspend for manualreview and pricing.BCBSMT has updated its policy explaining howmodifiers applied to services and procedures affectclaims processing. The policy was previously publishedas Surgical Service Modifier Compensation Policy, but isnow called Modifier Use When Coding Claims Policy.[ Fourth Quarter 2008 ] CapsuleNews10

Regular Business61Comprehensive Inpatient Rehab62Comprehensive Outpatient Rehab65End Stage Renal Disease71State of Local Public Health Clinic72Rural Health Clinic81Independent Laboratory99Other Unlisted FacilityMore information about place of service is available inthe Place of Service Compensation Policy and BCBSMTProvider Manual published at www.bcbsmt.com. If youhave questions, call the Customer Service Department at1-800-447-7828.Social Security Numbers Are Not Necessarily Health PlanID NumbersBCBSMT recently completed the transfer of individualmembership and products to the new claims processingsystem. A key aspect of the new system is that SocialSecu

4. Reset Office Staff User’s passwords 5. Assign Office Staff Users the Office Administrator role to allow them to also register and maintain other Office Staff User accounts Step Two: Create Office Staff Users To register your employees as Office Staff