© 2011 blue cross and blue shield of minnesota. all rights reserved. navigating minnesota’s...

© 2011 Blue Cross and Blue Shield of Minnesota. All rights reserved.

Navigating Minnesota’s Health Care Plans

June 28, 2012

Blue Cross and Blue Shield of MN and Blue Plus

Melody Bialke, LISW, MHPGov Prog Manager of Business Partnerships

Kathy Moline, RN, PHNManager, Integrated Health Management, Gov Prog

2

Overview

• Blue Plus Public Programs Products• Medicare Criteria and Blue Plus Authorization Process• Medicaid (State Plan) Home Care Authorization Process• Retro Review for Medical Necessity • Life of a Claim, Late Charges, Claim Attachments• Timely Filing• Contact Information for Claims and Authorizations• Provider Appeals • EW Claims Processing for Extended Home Care• Provider Resources• What is New in 2012

Blue Plus Public Programs Products

• Blue Plus serves:

• PMAP (Blue Advantage) members in 57 Counties

• MnCare members in 82 Counties

• MSHO (SecureBlue) members in 62 Counties

• MSC+ (Blue Advantage) members in 60 Counties

3

Home Care Order of Payer

1. Private Insurance or Medicare

2. Medicaid State Plan

3. EW, CADI, CAC, BI, DD Waivers for “extended” home care

5

Medicare Home Care Services• Blue Plus does not prior authorize Medicare eligible home care

services

• Agencies bill Blue Plus with Medicare PPS rates

• Determination of eligibility for Medicare services is made by the home

care agency; Blue Plus does not determine if services are eligible

under Medicare

• Medicare covers the following home care services:

• Skilled Nursing services

• Home Health Aide Services

• Physical therapy, Speech Therapy, Occupational Therapy

• Medical social services

6

Medicare Home Care, continued• Medical supplies are included in the PPS rate of payment; these are not separately

billable

• DME continues to be paid to the DME company

Coverage Guidelines:

1.Patients must be confined to their home

2.Under the care of a physician

3.Receiving services under a plan of care established and reviewed periodically

by a physician

4.Require skilled nursing care on an intermittent basis or physical therapy or

speech-language therapy, or

5.Have a continued need for occupational therapy

7

Medicare Home Care, continued

• Confinement to home: A member does not have to be bedridden to be considered home bound. However, the member’s condition should be one that there exists a normal inability to leave home and leaving home requires a considerable and taxing effort.

• Intermittent means provided or needed on fewer than 7 days each week or less than 8 hours per day for periods of 21 days or less

8


• Skilled nursing care:• Observation and assessment of the patient’s condition when

only the specialized skills of a medical professional can determine the patient’s status

• There must be a reasonable potential for change in a patient’s

condition that requires skilled nursing to identify and evaluate the

patient need for additional treatment or services

• Management and Evaluation of a Patient Care Plan:

Skilled nursing for the management and evaluation are covered when

underlying medical conditions or complications require that only a RN

can ensure the essential non-skilled care is achieving its purpose.

9


• Teaching and Training:

• Teaching and training that require skilled personnel are covered if

the skill to train the member or care giver requires the skills of an

nurse

• When it becomes apparent that the patient, family or caregiver will

not be able to be trained or is trained, care is no longer reasonable

and necessary for teaching

• Medication administration:

• Injections: IV, IM or SQ injections may require the skills of a nurse

to administer or to train the member

• Insulin injections are normally self injected and skilled nursing

visits are generally not necessary

10


• Oral Medications

• The administration of oral medications is not reasonable and necessary

skilled care in general

• Eye Drops / Topical Ointments

• Administration of eye drops and topical ointments does not require the

skills of a nurse and therefore are not considered reasonable and

necessary

• Tube Feedings

Adjustment, replacement, stabilization and suctioning of the tubes are

skilled nursing services; Feedings are not considered skilled care

11


• Nasopharyngeal and tracheotomy aspiration are considered skilled if needed

• Catheters• Insertion and sterile irrigation and replacement of catheters is

considered skilled

• Wound Care• Wound care visits are considered skilled when the services

require a nurse to evaluate and treat the wound

12


• Ostomy Care

• Ostomy care during the post-operative period and in the presence of associated

complications may be considered skilled

• Other care

Heat treatment when observation of a nurse is required

Medical gases - during the initial phase of new treatments to

provide education and assessment

Rehabilitation Nursing – such as bowel and bladder training

programs

Venipuncture – Visits for venipuncture can no longer be the sole reason for

Medicare home care services

13


• Home Health Aide• The reason for home health aide visits must be to provide

hands on personal care of the patient• Included are bathing, dressing, grooming, oral hygiene,

feeding, toileting, transfers, bed mobility and ambulation. • A HHA may be trained to perform wound care that does not

require the skills of a nurse• Assistance with medication that are ordinarily self

administered• Therapeutic exercises which support therapy goals

14

MA/Medicaid (State Plan) Home Care

• Most State Plan MA Skilled Nurse Visits and Home Health Aide home

care services do require a Blue Plus prior authorization

• This authorization process is different for seniors age 65+ in MSC+

and MSHO than it is for families and children in PMAP and MnCare,

due to the involvement of a Care Coordinator with seniors

• The MSHO/MSC+ Care Coordinator’s role is to coordinate the

provision of all Medicare and Medicaid health and long-term care

services for MHSO and MSC+ enrollees among different health and

social service professionals and across settings of care

15

Medicaid MA Home Care Guidelines

Covered Services• Intermittent home visits to initiate and complete nursing

tasks• Must be provided by a Medicare Certified home health

agency• Observation, assessment and evaluation of a member's

physical or mental health status• Completion of a procedure requiring substantial and

specialized nursing skill such as administration of IV therapy, intra-muscular injections and sterile procedures

16

Medicaid Home Care Guidelines, continued

Covered Services• Teaching and education / training requiring the skills of a

professional nurse•Post partum visits to new mothers and their newborns upon discharge from the hospital•Up to 2 visits per day if necessary•Home tele-home care visits if the member’s health status can be accurately measured and assessed without a need for a face-to-face hands-on encounter

17


Non-covered services• Telehomecare skilled nurses services that is a communication

between the home care nurse and recipient that consists solely of a telephone conversation, fax, electronic mail or a consultation between two health care providers.

• Nurse visits solely for the purpose of monitoring medication compliance with an established medication program

• Nurse visits to set up or administer medications when the need can be met by a pharmacy or the member or family can perform this function

18


Non covered services• Nurse visits to train other home care agency employees• Services performed for the sole purpose of supervision of the

home health aide or personal care assistant. • Visits for the sole purpose of blood samples when the

recipient is able to access these services outside the home• Administrative visits required by Medicare but not qualifying

as a skilled nurse visit• Nurse visits provided by an RN that is employed by a PCA

organization, or non-Medicare certified private duty nursing agency

19

MA Home Care Auth MSHO/MSC+ Seniors

• MSHO/MSC+ Care Coordinator faxes recommendation to Blue Plus

• Recommendation for Auth of MA Home Care (DHS-5841) for

persons on CADI, CAC, BI, or DD Waivers, OR

• MA Home Care Services Recommendation/Non-disability (Blue

Plus form 6.04.03), AND

• Customized Living tool, if applicable

• Blue Plus obtains necessary medical documentation from home care

agency

• Current CMS-485 form

• Home care records

• Blue Plus may contact Care Coordinator or home care agency for

additional information if needed20

MA Home Care Auth MSHO/MSC+ Seniors, cont.

• Blue Plus reviews MA State Plan requests and determines number of

visits based upon medical necessity and state plan guidelines

• Guidelines referenced for these reviews include DHS guidelines for

Home Care and applicable State Statutes:

https://www.revisor.mn.gov/statutes/?id=256B.0653

• Determinations are based upon the individual member needs, other

services the member has in place or available to them, state statue,

applicable guidelines and the request of the care coordinator,

physician and home care agency

21

MA Home Care Auth MSHO/MSC+ Seniors cont.

• Within 10 business days of the request (or 14 calendar days), Blue Plus

sends:

• an authorization determination letter to the member, and

• home care provider, and

• faxes the determination to the Care Coordinator

• Transitions of care:

• To assure that members have access to home care services to

meet their needs upon an acute condition change, Blue Plus will

approve up to 2 weeks of 10 home care visits without review for

members being discharged from an acute in-patient stay. The

Care Coordinator must fax in the home care recommendation

form to begin the services.

22

Extended EW Home Care MSHO/MSC+ Seniors• Elderly Waiver (EW) Extended HHA and PDN authorization

is done by the local Care Coordinator, based on the needs identified in the Long Term Care Consultation (LTCC) Assessment• Services do not need to meet medical necessity criteria, BUT

there must be a corresponding unmet need identified in the LTCC that is not being met with state plan or Medicare covered home care

• Must exhaust state plan home care first

• Extended HHA must be authorized in the same day as the State

Plan service

• Care Coordinator puts authorization in Bridgeview EW Service Agreement; authorization letter is sent to the provider

23

Families and Children MA Home Care Auth (under age 65 PMAP and MnCare)• Most home care services require authorization:

• Exceptions: • Nursing evaluation visits (not including PCA assessments)• Post Partum visits and family health protocols visits

MA Home Care Provider faxes a “Home Health Pre-Service Request” to Blue plus along with supporting information•Initial evaluation (for initial services only)•Current CMS-485 form•Home care records

• Within 10 business days of request BluePlus will review for medical necessity and send determination to member and home care provider

24

Families and Children Authorization cont.

MA Home Care Provider faxes a “Home Health Pre-Service Request” to Blue plus along with supporting information:

• Initial evaluation (for initial services only)• Current CMS-485 form• Home care records

25

Families and Children Authorization cont.

• Blue Plus reviews MA State Plan requests and determines number of visits based upon medical necessity and state plan guidelines. Guidelines referenced for these reviews include DHS Guidelines for Home Care and applicable State Statutes:

• https://www.revisor.mn.gov/statutes/?id=256B.0659

• Services are reviewed using the individual member

circumstances, services available to the member besides home

care, state statute, MHCP manual guidelines and the

recommendation of the home care agency.

26

Retro Review for Medical Necessity

• If a home care claim comes in and there is not an authorization on file, claim will pend for medical review

• Blue Plus will contact the home care provider for the necessary information

• If, after review, it is determined that the visit/service does not meet medical necessity, the claim will be denied

27

28

Life of a claim at Blue Cross• Blue Cross uses Availity for exchanging HIPAA mandated electronic

data interchange (EDI) transactions. You can get information on how

to register and conduct electronic transactions through availity.com

(1-800-Availity)

• Web-based Claim Submission, Eligibility & Remittance Tool

• One-stop shop with no-cost to providers

• Once registered, may sign up for live training webinars

• Pre-system edits align with Uniform Claims Companion Guides -

Health.state.mn.us/auc

•Effective November 14, 2011, provider remittances generated on this

date and forward are no longer available through providerhub.com

Electronic Transactions

Blue Cross accepts the submission and/or generates the following HIPAA compliant transactions:

• Health Care Claim (837 P and D)• Health Care Claim Payment/Advice (835)• Health Care Eligibility Benefit Inquiry and Response

(270/271)• Health Care Claim Status Request and Response

(276/277)• Health Care Services Review- Request for Review and

Response (278)

29

Claims Payments

• Time-frame for processing clean claims • Per DHS contract, within 30 days of receipt

• Provider Remittance is available every week and at month end• Must register through Availity to receive electronic 835 - Health Care Claim Payment/Advice

• Payments are sent weekly to participating providers

30

Claim Attachments

• Electronic attachment detailed instructions can be found on Blue Cross website as well as frequently asked questions and answers

• Blue Plus does accepts claims with attachments electronically• The claim must adhere to the electronic rules found in the

Uniform Companion Guides

• Related attachment should be faxed to Blue Plus at 1-800-793-6928

• Attachment cover sheet can be found on the AUC website & must be used as the first page on each claim attachment

31

Claim Attachments

• If the attachment is too large for a fax then you can mail the attachment directly to Blue Cross Blue Shield of MN at:

Blue Cross Blue Shield of MinnesotaP.O. Box 64338St Paul. MN 55164-0338

32

Timely Filing Deadlines

• Participating providers are required to submit original claims within six (6) months after the date of service

• Replacement claims timely filing• Six calendar months from the process date of the

predecessor claim

• Cancel claims• No timely filing limit

• Provider-submitted appeals• 90 days from the process date of the claim

33

Integrated Health Management Government Programs Intake

PMAP, MNCARE, MN Senior Care Plus, MSHO

• (651) 662-5540 or 1-800-711-9868

•FAX: (651) 662-4022 or 1-866-800-1665

•This number may also be utilized to obtain information about who the member’s care coordinator is

34

Provider Services

Listen for the current phone options when you call

• (651) 662-5200 or 1-800-262-0820 (toll free)

•Fax number is (651) 662-2745

35

Provider Appeals

•MN Blue Cross participating providers have the right to appeal any claim denial by completing the appropriate appeal form listed on the AUC website

•We allow a 60 day time frame for completing a provider appeal once it is submitted to us

36

Elderly Waiver Claims – Extended Home Care

• As of July 1, 2010 all Elderly Waiver claims are processed and paid by Bridgeview Company (formerly FirstSolutions) on Blue Plus’ behalf

• This includes Extended HHA, Extended PCA, Extended PDN

• Bridgeview Company’s website for EW claims• www.bridgeviewcompany.com

• Changes are posted on their website and are communicated via remittance advices and mailings

37

Provider Resources

• www.bluecrossmn.com • Bottom left corner under Access Your Secure Site, click

providers.bluecrossmn.com for access to:

• Blue Cross Provider Policy and Procedure Manual

• Medical Policy

• Provider Bulletins

• Provider Quick Points

• Provider Press Newsletter

• “How-to” documents

• Forms

• Provider Web Self-service

38

What Is New In 2012

• Maintenance therapies no longer covered for ages 21 and above

• No longer any Medicaid coverage for services delivered or items supplied outside of the US. (Canada has been removed from the allowable list of countries to receive services)

• Providers may now seek payments from a member for non-covered services not otherwise eligible for payment (Signed waiver required)

39

Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association.

© 2011 blue cross and blue shield of minnesota. all rights reserved. navigating minnesota’s...

Documents