July 2008 Provider Network News 3 Professional Provider Office Manual www.bcbsla.com/providers www.bcbsla.com/ilinkblue 3 News Network Provider 2008 July 23XX6767 R12/16 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 PROFESSIONAL PROVIDER OFFICE MANUAL This manual is designed to provide information you will need as a participant in the Blue Cross and Blue Shield of Louisiana Professional Provider Network—it is an extension of your Professional 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 www.bcbsla.com/ providers. If you have questions about the information in your manual or your participation as a network provider, please call Network Administration at 1-800-716-2299, option 1 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 Professional 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 Professional Provider Office Manual as needed. The Professional Provider Office 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 Mail 8 ' , 7 7 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross andProfessional Blue Shield Provider Association Office and Manual incorporated as Louisiana Health Service & Indemnity Company.December 2016 3 P.O. Box 98029, Baton Rouge, Louisiana 70898-9029 • 1-800-716-2299 Professional Provider Office 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 Allied Health Providers 10 Locum Tenens 11 Non-participating Providers 11 Credentialing Program 12 Provider Availability Standards 14 Provider Directories 15 Provider Diversity Information 16 Refer Members to Network Providers 16 Section 2: Network Overview 17 Network Overviews 17 ® BlueCard Program 23 Consumer Directed Health Care 26 HMO of Louisiana Inc.’s Blue Advantage (HMO) Plan 29 Medicare Advantage Members from Other Blue Plans 29 Section 3: Member Engagement Tools 30 Section 4: Claims Submission 32 Filing Claims 32 Timely Filing 32 Refunds Process 33 Procedure and Diagnosis Codes and Guidelines 33 Diagnosis Code Specificity 34 Commercial Risk Adjustment 35 Claims Re-submission (Re-filing) 35 Adjustment & Void Claims Submission 35 Overpayments 36 National Provider Number (NPI) 37 Modifiers 38 Reporting National Drug Code (NDC) on Claims 44 Equipment, Devices and Supplies 45 Code Editing: Billing Practices Subject to Reduction 45 Multiple Service Reduction for Diagnostic Imaging Services 46 Provider Access to iLinkBlue Medical Coding Section 47 CMS-1500 Claim Form Filing Guidelines 47 CMS-1500 Claim Form 48 Place of Service Codes 59 UB-04 Claim Form 60 Coordination of Benefits (COB) 66 Subrogation 66 Employment-related Injuries or Illness 67 Medicare Supplemental Claims 68 Section 4-A: Electronic Claims Submission & Payment 71 Blue Cross and Blue Shield of Louisiana Professional Provider Office Manual December 2016 5 Electronic Data Interchange (EDI) 71 iLinkBlue 71 Electronic Remittance Advice/Payment Register 72 Electronic Funds Transfer (EFT) 73 EFT Application Guide 74 EFT Application 77 Section 5: Reimbursement 79 Allowable Charges 79 New Codes 79 Unlisted Drug Codes 80 Not Seperately Reimbursable Codes 80 Member Cost-sharing 80 Claims Disputes and Review 81 Claims Dispute Form 83 Payment Register/Remittance Advice Explanation 85 Section 6: Billing Guidelines 87 Ambulance 88 Anesthesia 95 Autism 104 Behavioral Health 105 Chiropractic and Therapy Services 110 Concierge Medicine 114 Delivery of Pregnancy 115 Dialysis 117 Dietitian Billing Guidelines 118 Drug Screening Assays 120 Durable Medical Equipment (DME)/Home Medical Equipment 121 Home Health Agency 129 Incident-to Billing Guidelines 133 Infusion Therapy 136 In-Office Procedures 142 Laboratory - Using Preferred Labs 142 Nurse Practitioner 146 Off-campus Services Billing Guidelines 146 Physical & Occupational Therapy Re-evaluation Billing Guidelines 147 Rural Health Clinic and Federally Qualified Health Clinic Billing Guidelines 147 Home Sleep Study for Obstructive Sleep Apnea(OSA) 1 4 9 Sleep Study 149 Specialty Pharmacy Billing Guidelines 151 Telemedicine Billing & Reimbursement 153 Urgent Care/After Hours Centers 156 Section 7: FEP Benefit Information 158 Standard Option 158 Basic Option 158 Cancer Screening 159 Provider Tips 159 FEP Non-Network or No Network Claims Processing 159 Claims Submission and Contact Information 159 Section 8: Medical Management 160 Overview 160 Medical Necessity Review Organization 160 Authorization Process 160 Blue Cross and Blue Shield of Louisiana Professional Provider Office Manual December 2016 6 Concurrent Review 162 Case Management 163 Disease Management 163 Retrospective Review 164 Medical Policy Inquiry 165 Direct Access 166 Services That Require Authorization Prior to Rendering Services 167 OGB Plan Services Requiring Authorizations 168 Authorizations for High-tech Imaging Services 169 Drug Authorizations 170 Authorization Penalties for Providers 170 Medical Records 171 Adult and Pediatric Ambulatory Medical Review Definition of Guidelines 171 Quality Management Program 174 Step Therapy Program 174 Maternity Management Program - Healthy Blue Beginnings 175 Section 9: Medical Appeals 176 Standard Administrative Appeal 177 Standard Medical Appeal 178 Expedited Internal Medical Appeal 179 Expedited External Medical Appeal 180 Section 10: General Disputes 182 Section 11: Preventive Medicine 184 Benefit for Women’s Preventive Services 184 Preventative Medicine Guidelines 184 Section 12: Communicating with Blue Cross and Blue Shield of Louisiana 185 Electronic Benefit Verification-iLinkBlue 185 Provider Services Voice Response Telephone System Call Center 185 Customer Service 186 Preadmission Authorization 186 Provider Network Administration 186 Provider Relations Services 187 Section 13: Definitions 188 Summary of Changes 196 Blue Cross and Blue Shield of Louisiana Professional Provider Office 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 [email protected] 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 Electronic Services www.bcbsla.com EDI Clearinghouse www.bcbsla.com/ilinkblue [email protected] 8 [email protected] (225) 291-4334 1-800-216-BLUE (1-800-216-2583) BlueCard® Eligibility Line Appeals and Grievances/Provider 1-800-676-BLUE (1-800-676-2583) Dispute Resolution Blue Cross and Blue Shield of Louisiana Member Benefits Appeals and Grievance Department Call the number on the member’s ID card. P.O. Box 98045 Fraud & Abuse Hotline Baton Rouge, LA 70898-9045 1-800-392-9249 1-800-376-7741 or (225) 293-0625 Blue Cross and Blue Shield of Louisiana Professional Provider Office Manual December 2016 8 Section 1 NETWORK PARTICIPATION Participating providers are those physicians and allied health providers who