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Catch One of These Radiology Management Program Webinars PROVIDERNews Catch One of These Radiology Management Program Webinars Providers who weren’t able to attend the Radiology Management Program overviews held at our recent Mountain State Provider Workshops will have more opportunities to learn this important information. Twelve webinar sessions have been scheduled in November and December to allow providers to hear tips for how to prepare for the program. Representatives from National Imaging Associates, Inc. (NIA) will conduct two 90-minute sessions on each of the following dates: ® Nov. 16, 2010, 8 a.m. and noon ® Nov. 17, 2010, 8 a.m. and noon ® Dec. 7, 2010, 8 a.m. and noon ® Dec. 8, 2010, 8 a.m. and noon ® Dec. 14, 2010, 8 a.m. and noon ® Dec. 15, 2010, 8 a.m. and noon Registration is required. Please click here to access the registration form. (Continued on page 2) Inside This Edition: Radiology Management Program 2 Prescription Drug Benefit Management Moving 10 Paperless EOB and EFT 2 Watch Your Mail for News about FreedomBlueSM NaviNet® Verification Process 3 PPO and BlueRxSM PDP Changes 11 Mountain State Automates Electronic Changes for Service Benefit Plan FEP Members 11 Professional Claim Adjustments Requests 4 National Consumer Cost Tool Initiative 13 Mountain State to Revise COB Process 6 Mountain State to Update Its List of Procedures Coverage for Certain OTC Medications 6 Requiring Authorization 13 October 2010 Medicare Advantage News 7 Contracting/Reimbursement Update 14 Need help getting ready for ICD-10? 8 Please Note Important Holiday Observances 16 HIPAA News 9 Welcome to Our Newest Groups 16 Procedure Codes Relevant to Dental Services 10 Medical Policy Updates 17 PROVIDERNews Catch One of These Radiology Management Program Webinars (Continued from page 1) You will need a computer with Internet access to view the educational materials presented during the webinar. Please send your completed registration form to Kristy Over by fax at 1-888-656-6350 or via e-mail at [email protected] at least one (1) week before the scheduled webinar date. After you RSVP, you will receive a confirmation e-mail from NIA for the webinar session you selected. Radiology Management Program: First Date to Begin Contacting NIA for Prior Authorization is Dec. 20, 2010 The Radiology Management Program begins Jan. 1, 2011. For dates of service on or after Jan. 1, 2011, providers can begin contacting NIA on Dec. 20, 2010. For additional details about the Radiology Management Program, please see page 4 of the August 2010 issue of Provider News. Moving to Paperless Explanation of Benefits (EOB) Statements and Electronic Funds Transfer (EFT) As announced previously, beginning Oct. 1, 2010, and continuing throughout 2011, Mountain State will require our network practitioners to enroll in NaviNet® and receive paperless EOB statements and EFT. These electronic transactions provide enhanced protection of both member and practitioner data and provide you with faster reimbursement. For more information, please see page 2 of the August 2010 issue of Provider News. 2 October 2010 NaviNet® Streamlines Verification Process for Hospital Clerk Hold the phone! The expression could certainly be used to describe how Laurel Shourds would spend much of her past days as an insurance verification clerk at St. Joseph’s Hospital in Parkersburg. Over the years, Ms. Shourds had come to accept being on hold for extended periods when placing telephone calls to insurers to verify patient benefits and to obtain authorizations for procedures. So when she heard that an Internet-based ® tool called NaviNet could help her get more Laurel Shourds, left, with Brenda Amos, Patient Access Supervisor, accomplished in less time, she was skeptical. at St. Joseph’s Hospital in Parkersburg. Ms. Shourds is now able to provide insurance verification information to the hospital a full month “When you do a job one way for a number of years, ahead of scheduled procedures, thanks to NaviNet. you’re resistant to change,” Ms. Shourds explains. “The thought of doing things electronically was a bit Ms. Shourds finds comfort in NaviNet’s reliability intimidating. I wasn’t confident that I’d be able to get and speed. “I use it the most for Mountain State the information I needed.” patients,” she notes. “I find there’s very little downtime and when there is downtime, it’s taken But in a very short time, she was happy to discover care of very quickly. I like being able to go into the what she’d been told about NaviNet was true. Within system and, within a few minutes, find out exactly a week, she was comfortable with the system and what I’m looking for. was saying goodbye to the telephone for verifying the benefits of the hospital’s Mountain State “The first thing I do in the morning is sign on to patients. NaviNet because I’m in and out of it all day.” “Once I realized how much information I could get, Now that she’s experienced the advantages of how quickly I could get it and how dependable NaviNet, she can’t imagine going back to the NaviNet is, I was hooked,” she recalls. “I’m definitely telephone. a fan.” “The hold times were frustrating,” she says, Learning NaviNet was easy, Ms. Shourds adds, and noting that holds could last anywhere from three within a week she was comfortable using it. “Once I to 15 minutes. “The sheer volume of how many understood the menus, where I needed to go to get verifications and authorizations I have to do is what I needed, it didn’t take that long. It’s very user significant.” Because Ms. Shourds could only do friendly. Once you get into a plan, the information is verifications and authorizations for three patients at easy to look at, read and understand,” Ms. Shourds a time by telephone, it really slowed her down. says. For each patient, Ms. Shourds must determine his The layout is clean and features terms that are easy or her deductible, coinsurance and out-of-pocket to comprehend, she adds. “The facts and figures are maximums and record how much he or she has met right in front of you, where you need them.” or still owes. She enters that data into the hospital’s system, which the preregistration staff uses to inform patients of their financial responsibility prior to their procedure. (Continued on page 4 3 PROVIDERNews NaviNet® Streamlines Verification Process for Hospital Clerk (Continued from page 3) “With NaviNet, I can do as many (verifications) as The process isn’t always as smooth for other health I need to whenever I need to,” she says. NaviNet plans that do not have a system like NaviNet, she says. makes my job so much more pleasant. It’s enabled me to get out farther on our schedules for high- “We’ve had an experience where a patient was dollar surgeries, CAT scans, MRI and nuclear already in the hospital waiting for a procedure and medicine procedures.” we could not proceed until I could get through to someone from the health plan to verify the patient’s Ms. Shourds prefers to have the information eligibility and benefits,” Ms. Shourds recalls. available to the preregistration staff at least three weeks before scheduled procedures. Thanks to After experiencing its many advantages, NaviNet, she’s been able to provide that data one Ms. Shourds would recommend NaviNet to her month ahead of procedures. colleagues. “By all means, use it,” she says. “It’s quick, it’s reliable, and it’s user friendly. “My life would certainly be a lot more hectic without it.” Mountain State Automates Electronic Professional Claim Adjustments Requests You, along with Mountain State Blue Cross Blue original claim number Shield, benefit from efforts to streamline claim assigned by Blue Cross adjustments. The HIPAA 837P, which allows you to Blue Shield is required on submit a claim adjustment request, has now been this type of submission. automated. Frequency Type 8 is a Void/ Cancellation of a prior claim. Frequency Type 8 Please analyze your adjustments to determine is used to completely void a claim that was reported whether there are opportunities to initiate electronic in error. The original claim number assigned by claim adjustment requests. It is important that you Blue Cross Blue Shield is required on this type of also find out if these additional claim types are submission. supported by your claim submission vendor. In the HIPAA 837P Claim Transaction, the There are three valid Frequency Type Claims that Frequency Type Code is reported in the 2300 Loop, can be initiated: CLM05-3 element. The original claim number is reported in Loop 2300, ORIGINAL REFERENCE Frequency Type 1 is an original claim. All new NUMBER (ICN/DCN) REF segment. claims are submitted with this value. Adjusted claims can also be submitted using the Frequency Type 7 is a replacement of a prior NaviNet® Claim Submission/1500 claim submission claim. Frequency Type 7 is used to correct data transaction, then selecting the appropriate reported incorrectly on the original claim. The frequency type code, and providing the original claim number on the “Header” page. (Continued on next page) 4 October 2010 When to bill for a replacement Mountain State action Examples of corrected claims that claim (Frequency Type 7) can be submitted When to use Use Frequency Type 7 when Mountain The initial claim is identified based on the When a change is made to a service, State has processed a specific claim for original claim number reported. such as: payment and you, the provider, identified ® incorrect procedure or diagnosis code an error on the original claim that needs The replacement claim data is used to to be corrected.
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