2016 contracting professional relations cap report · 2020. 11. 2. · cap 4 note — in 2016, for...

2016 Contracting

Professional RelationsCAP REPORT

CAP Report / July 2015 2Contains Corporate Information

INTRODUCTION ...

Blue Cross and Blue Shield of Kansas (BCBSKS) is the insurer Kansans trust with their health, and the reasoning for such is documented in the following pages.

BCBSKS continues to offer contracting providers top-notch services, including provider network services personnel and representatives dedicated to serving providers and their offices, along with a competitive Maximum Allowable Payment (MAP) and the opportunity for providers to earn additional revenue through our Quality-Based Reimbursement Program (QBRP).

Please read the following pages for specific information related to 2016 provider Competitive Allowance Program (CAP) contracting. If you need clarification or additional information, contact provider network services or contact your professional relations representative.

Professional Relations Staff Location Phone Numbers Doug Scott, Director Topeka (800) 432-0216 ext. 8831 (785) 291-8831Robyne Goates, Manager Topeka (800) 432-0216 ext. 8206 (785) 291-8206Diana Evans Topeka (800) 432-0216 ext. 8716 (785) 291-8716Darin Fieger Topeka (800) 432-0216 ext. 8207 (785) 291-8207Christie Blenden Topeka (800) 432-0216 ext. 8651 (785) 291-8651Vikki Lindemuth Topeka (800) 432-0216 ext. 7724 (785) 291-7724Provider Network Services Topeka (800) 432-3587 (785) 291-4135 option 1 or 3 option 1 or 3Kyle Abbott Wichita (800) 432-0216 ext. 1674 (316) 269-1674Velda Fresquez-Gray Wichita (800) 432-0216 ext. 1674 (316) 269-1674Debra Meisenheimer Hutchinson (620) 663-1313 Gwen Nelson Dodge City (620) 225-0884

CAP Report / July 20153 Contains Corporate Information

#1 BCBSKS is top-ranked for Provider Satisfaction.

975,997 BCBSKS serves 975,997 members across all lines of business, including BlueCard, as of May 31, 2015.

BY THE NUMBERS ...

◄ 699,171BCBSKS serves 699,171 members locally, as of May 31, 2015.

◄ $40 MillionBCBSKS is projecting $40 million in QBRP incentives in 2015.

10.30% BCBSKS spends 10.30 percent of annual premium income on administrative expenses.

99% BCBSKS contracts with 99 percent of all physicians in the Plan area.

◄ 97%BCBSKS contracts with 97 percent of all professional providers in the Plan area.

◄ 100%BCBSKS is 100 percent URAC accredited in health plan, case management and disease management.

Blue Cross and Blue Shield of Kansas provides the best service in the industry and strives to be the health insurance company of choice for our members and providers.

PCMH BCBSKS is the only carrier in Kansas supporting Patient-Centered Medical Home (PCMH).


NOTE — In 2016, for the majority of our business, non-contracting providers’ services will be paid direct to the member at a charge up to 80 percent of the MAP (i.e., there is a 20-percent penalty for members receiving services from a non-contracting provider), subject to member benefits. In addition, assignment of benefits to non-contracting providers is not allowed.

► Local member contracts structured to allow 100 percent of the MAP for participating CAP providers (subject to member benefits).

► Direct payment from BCBSKS, which minimizes your collection efforts and increases cash flow.

► A dedicated field staff available to visit your office to address any operational issues.

► Access to professional relations provider network services personnel to answer policy questions or obtain assistance with claim coding questions.

► Website (bcbsks.com) and self-service access through Availity, which improves your office efficiencies and maximizes your employee resources.• Secured services include detailed claims

payment information, member eligibility, remittance advice, and provider enrollment information.

• Other services including training modules, podcasts, newsletters, manuals, policy memos, and medical policies/guidelines.

► Detailed claim-payment information provided to both you and the member explaining their financial responsibilities.

► Opportunity to earn additional revenue through the Quality-Based Reimbursement Program (QBRP).

► Electronic remittance advice and payment capabilities.

► Opportunity to participate on specialty liaison committees and provide direct input in the development of medical policies and emerging issues.

► Contracting providers’ names made available to BCBSKS members through a number of sources, including the internet, employer groups, and other contracting providers for referral purposes, which increases the potential for new patients.

► Periodic workshops conducted by professional relations staff that delivers continuous training for new and experienced medical assistant staff, helping update your staff on new administrative procedures to ensure timely claim payments.

THE VALUE IN CONTRACTING ...BCBSKS provides business services that bridge the gap between the delivery and financing of health care. Services creating significant value for contracting providers include:


2016 REIMBURSEMENT AND POLICY MEMO CHANGES ...On June 26, 2015, the BCBSKS Board of Directors met and approved reimbursement and policy memo changes for 2016. A summary of the Policy Memo changes is enclosed for your review. Highlights of the 2016 reimbursement are noted below. We continue to build on the Quality-Based Reimbursement Program (QBRP) started in 2012 to encourage higher quality and better control of health care costs. Our reimbursement program for 2016 will continue to create opportunities for providers to earn incentives by meeting the criteria as outlined in the 2016 QBRP as described on pages 7-12.

A charge comparison report reflecting reimbursement changes for 2016 is available by contacting your professional relations representative or professional relations provider network services. The charge comparison is based on services billed by you during the first five months of 2015. As a reminder, the format of the charge comparison report changed in 2015. The new format provides the lesser of your charge or the MAP for each procedure code you performed thus far in 2015. In addition, the new report will show whether each procedure code qualifies for QBRP.

Increasing ▲ No change ▬ Decreasing ▼Evaluation and Management (E&M) codes (eligible for QBRP)

Clinical lab codes (not eligible for QBRP)

Professional consultation codes (eligible for QBRP)

Undervalued CPT codes (eligible for QBRP)

Anesthesia conversion factor at $58.37 (eligible for QBRP)

Overvalued CPT codes (eligible for QBRP)

Ambulance base rates for fixed wing and rotary wing and codes A0433 and A0434 (eligible for QBRP)

Pharmaceuticals (not eligible for QBRP)

Mileage rates for fixed wing and rotary wing (eligible for QBRP)

Sleep medicine (eligible for QBRP)

Durable Medical Equipment (DME) (eligible for QBRP)

Services billed by primary care providers located in counties with a population of 13,000 or less. See county listing on Page 13. Providers meeting this requirement will receive a 5 percent add-on to the MAP on all eligible CPT codes. (not eligible for QBRP)

Please note that along with base rate changes, additional reimbursement is available through the QBRP program where noted. (See QBRP section, pages 7-12.)

OVERVIEW OF 2016 REIMBURSEMENT ...


85 percent 70 percent 50 percentAdvanced Practice Registered Nurses (APRNs) [not including Certified Registered Nurse Anesthetists (CRNAs)]

Community Mental Health Centers

Certified Occupational Therapy Assistants (COTAs)

Chiropractors Licensed Clinical Marriage and Family Therapists

Certified Physical Therapist Assistants (CPTAs)

Clinical Psychologists Licensed Clinical Professional Counselors

Licensed Athletic Trainers (LATs)

Occupational Therapists Licensed Clinical Psychotherapists

Physical Therapists Licensed Specialist Clinical Social Workers (LSCSWs)

Individual Intensive Support (IIS) providersPhysician Assistants Outpatient Substance Abuse

Facilities

Speech Language Pathologists

Autism Specialists

Licensed Dieticians

The allowances for the following specialties have been set at the identified percentages of the MAP (no change for 2016).

TIERED REIMBURSEMENT ...


The BCBSKS Quality-Based Reimbursement Program (QBRP) is designed to promote efficient administration and improved quality with better patient care and outcomes. Contracting BCBSKS providers have an opportunity to earn additional revenue through add-ons to allowances for meeting the defined quality metrics.

IMPORTANT REMINDER — The 2016 QBRP program is effective for services performed January 1, 2016 through December 31, 2016. Since the 2016 CAP letter is sent out in July 2015, providers have several months to prepare to meet the various QBRP metrics and qualify for incentives effective January 1, 2016, in accordance with the metric review schedule (see pages 11-12). Please read the requirements and metrics for the 2016 QBRP program so you are prepared to maximize the available incentives.

Criteria for 2016In accordance with the 2016 Policy Memo No. 1, Section XXX. Reimbursement for Quality, this document describes the components of QBRP effective January 1, 2016 through December 31, 2016. This program applies to all CAP and Solutions professional providers and services except for clinical lab, pharmacies and pharmaceuticals, and dentists. This program will offer an opportunity for eligible providers to earn increased reimbursement based on a three-group approach (Groups A, B and C). This reimbursement will be in addition to the established base MAPs for 2016.

In order to pay incentives on the clinical-based targets in Group C, we developed a doctor/patient registry. BCBSKS will review claims for the preceding 12 to 24 months and attribute patients to primary care physicians based on the frequency of office visit encounters with a given physician. In the event multiple primary care physicians have the same number of encounters for the same patient, the patient will be attributed to the physician with the most recent encounter.

The quality-based incentives will be earned at the individual provider level unless otherwise specified.

The number of components in the program will vary depending on provider type, with a maximum of 17 available to primary care physicians. An eligible provider may independently qualify for each component, except when measured on a group basis. The QBRP metrics are multiplied individually by the MAP, then totaled with the MAP to determine the total reimbursement. The 5 percent rural access payment is separate and distinct from QBRP, and is calculated and applied in the same way as the QBRP amounts.

In order for incentive payments to begin January 1, 2016, BCBSKS will use information on file or available from outside sources to determine which incentives providers qualify for based on unique provider individual NPI numbers, billing NPI numbers or tax ID, whichever is applicable. Confirmation notices with the qualifying incentive category, amount, and effective date will be generated for each individual provider and sent by email to the address on file. Email delivery of the confirmation notices for QBRP 2016 incentives effective January 1, 2016 will be sent mid-December 2015.

2016 PROFESSIONAL PROVIDERS QBRP ...


2016 PROFESSIONAL PROVIDER QBRP ...

QBRP PREREQUISITES AND GROUPS FOR PROVIDERSQBRP Participation Prerequisites

Providers must conduct business with BCBSKS electronically (i.e. turn off paper). Providers must submit all eligible claims electronically, accept electronic remittance advice documents (ERAs: either through receiving the ANSI 835 transaction or by downloading the RA from the BCBSKS website), and receive all communications (newsletters, etc.) electronically.

Group A Applies to all eligible contracting professional providers and to all eligible/covered CPT codes (excludes Lab, Drugs, and Dental).

Group B Applies to all prescribing provider types (MD, DO, DPM, OD, PA, APRN) and to all eligible/covered CPT codes (excludes Lab, Drugs, Dental).

Group C Applies to primary care professionals including supervised mid-levels (FP, GP, Peds, IM, PA, APRN) and only to covered E&M codes. Group C incentives are earned at the group level (for physicians with attributed members) with the exception of NCQA Diabetes, Heart Stroke Recognition and PCMH, which are incentivized at the individual level. New providers joining a group or changing tax IDs will not be eligible for the HEDIS metrics under the new arrangement until the refresh period.

We will continue monthly/quarterly reviews throughout 2016 to identify providers who did not qualify for incentive(s) beginning January 1, 2016, but may subsequently qualify for incentive(s). When a provider newly qualifies for an incentive(s), the incentive(s) will be effective the first of the following month or quarter, whichever is applicable. An updated confirmation notice will be emailed to the provider to include the new incentive category and effective date.

We will conduct a QBRP refresh in the first and second quarters (depending on the metric) of 2016 for an effective date of July 1, 2016 to determine if providers are continuing to earn the incentive payments effective earlier in the year. If the refreshed data indicates a provider is no longer earning an incentive(s), then the associated QBRP incentive(s) will cease beginning July 1, 2016 until such time the provider again earns the incentive(s) as determined through monthly/quarterly monitoring. If a provider ceases to meet the metric(s), he/she will receive a new communication advising of the change in their QBRP incentive(s) qualifications. Likewise, if a provider no longer meets the metric(s) and later re-qualifies to meet the metric(s), he/she will receive a new communication to inform them of the new effective date for receiving the associated QBRP incentive(s).


Metric % Group Description Qualifying Period

Electronic Self-Service

3.0 A Must use Availity portal or ANSI 270/271 & 276/277 transactions to electronically obtain BCBSKS patient eligibility and benefit information. Must obtain claims status information through the Availity portal. Electronic access must occur at least 65 percent of the time compared to the provider’s total number of queries to BCBSKS, regardless of the mode of inquiry. Providers billing under a single tax ID number will have their inquiries combined for determining the 65 percent.

Quarterly

KHIE inquiries

1.5 B Each prescribing provider must inquire to an approved Kansas Health Information Exchange (KHIE) organization at least 60 times per quarter to earn this incentive. Groups with EMR systems that only report by tax ID number must meet the aggregate 60 inquiries multiplied by the number of prescribing providers in the group. Groups may choose to be counted on a group or individual basis (see page 12). Each provider must have a user ID.

Quarterly

(NEW) KHIE HL7 use — Must have real-time connectivity to qualify for:

a-KHIE HL7.Demographics,

admissions, discharge,

transfer

1.0 B Must send all records for demographics, admissions, discharge, and transfers. This includes office visits.

Quarterly

b-KHIE HL7.Progress

notes

1.0 B Must send progress notes on all patient encounters. Quarterly

c-KHIE HL7.Diagnosis and

Procedure coding

1.0 B Must send diagnosis and/or procedure coding on all patient encounters.

Quarterly

d-KHIE HL7.Lab reporting

0.5 B Must send all lab reports on all patient lab tests. Quarterly

e-KHIE HL7.Medication

records

1.0 B Must send medication history on all patient encounters.

Quarterly




Use of Electronic Prescriptions

.75 B Must electronically access member benefit information for eligibility, formulary, and medication history a minimum of 90 times per quarter.

Quarterly

Generic Utilization Rate

.75 B Minimum generic prescribing of 75 percent (for all BCBSKS members with a prescription drug benefit).

Quarterly

(NEW) Cover My Meds (electronic prior authorization)

2.5 B Use Cover My Meds prior authorization requests for drugs requiring prior authorization.

Quarterly

Specialty Pharmacy

3.0 B Prescriber must have at least five specialty pharmacy prescriptions (per quarter) and at least 50 percent of all specialty pharmacy prescriptions must be filled through Prime Specialty Pharmacy.

Quarterly

Diabetes Recognition Program

.75 C Provider must be recognized as participating in the NCQA Diabetes Recognition Program.

Monthly

PCMH Recognition (a OR b) — a. Level 1 or Level 2

.75

OR

C Provider must achieve NCQA and/or URAC Patient Centered Medical Home recognition Level 1 or Level 2.

Monthly

PCMH Recognition — b. Level 3

1.75 C Provider must achieve NCQA and/or URAC Patient Centered Medical Home recognition — Level 3. *If a provider qualifies, they cannot also receive PCMH Level 1 or 2 incentive.

Monthly

Childhood Immunization MMR

.75 C The percentage of children 2 years of age who had one Measles, Mumps, and Rubella vaccine by their second birthday (turned age 2 in the measurement period). Must be greater than or equal to 60 percent to meet the metric, calculated at the provider group level for all eligible providers having at least one attributed/eligible patient for MMR.

Semi-annual

Immunization for Adolescents Tdap

.75 C The percentage of adolescents 13 years of age (turned age 13 in the measurement period) who had a Tdap vaccine by their 13th birthday. Must be greater than or equal to 70 percent to meet the metric, calculated at the provider group level for all eligible providers having at least one attributed/eligible patient for Tdap.

Semi-annual


Note — LDL screening was removed for 2016 because it is no longer a HEDIS measure.


QUALIFYING FOR USE OF ELECTRONIC PRESCRIPTIONS, GENERIC UTILIZATION RATE, COVER MY MEDS, AND SPECIALTY PHARMACY INCENTIVES ...The following is a list of incentive effective dates and the corresponding qualifying periods:

Qualifying Period: Incentive begins: Sept. 1 - Nov. 30, 2015 Jan. 1, 2016 Dec. 1 2015 - Feb. 29, 2016 April 1, 2016 March 1 - May 31, 2016 July 1, 2016 June 1 - Aug. 31, 2016 Oct. 1, 2016

QUALIFYING FOR KHIE AND ELECTRONIC SELF-SERVICE INCENTIVES ...The following is a list of incentive effective dates and the corresponding qualifying periods:


Breast Cancer Screening

.75 C The percentage of women 50 to 74 years of age (52 to 74 as of the end of the measurement period) who had a mammogram anytime in the last two years. Must be greater than or equal to 60 percent to meet the metric, calculated at the provider group level for all eligible providers having at least one attributed/eligible patient for breast cancer screening.

Semi-annual

NCQA Heart Stroke Recognition Program

.75 C Provider must be recognized as participating in the NCQA Heart/Stroke Recognition Program.

Monthly


Qualifying Period: Incentive begins: Aug. 1 - Oct. 31, 2015 Jan. 1, 2016 *Sept. 1 - Nov. 30, 2015 Jan. 1, 2016 Nov. 1, 2015 - Jan. 31, 2016 March 1, 2016 Feb. 1 - April 30, 2016 June 1, 2016 May 1 - July 31, 2016 Sept. 1, 2016 Aug. 1 - Oct. 31, 2016 Dec. 1, 2016*Special qualifying period to allow for additional time to establish HL7 connectivity and use.


Prescribing providers need to log in and query KHIE — Through a Kansas Department of Health and Environment-approved health information organization (HIO), each provider must inquire at least 60 times per quarter. The authorized HIOs in Kansas are Kansas Health Information Network (KHIN) and Lewis and Clark Information Exchange (LACIE).

Group vs. Individual reporting based on EMR — Provider groups with EMRs that only report by Tax ID must meet an aggregate of 60 inquires multiplied by the number of prescribing providers in the group. If the query to the exchange is performed within the EMR or if a group requests in advance to report in aggregate, all patient queries of KHIE will be counted and reported to BCBSKS in aggregate.

Groups requesting the aggregate method — The group must request this method in advance. Once this method has been requested, group reporting will be in effect through 2016. Once aggregate reporting has been requested, a delegated staff member may log in using their own name and password. The query will be attributed to the prescribing provider group in order to achieve the query threshold (number of prescribing providers multiplied by 60), and either all providers will qualify or none will qualify.

Notifying BCBSKS if reporting at group level rather than individual — Send your request in an email to [email protected]. Include group name, tax ID and billing NPI. All prescribing providers within the group who also have established user names with their KHIE organization will be qualified to receive the QBRP incentive if the group meets the required number of queries.

No action necessary for groups already reporting by the aggregate method — Groups signed up to report as aggregate in 2015 will continue as such until BCBSKS is notified of the request to return to individual reporting.

Patient queries do not have to be BCBSKS members — All patient queries qualify. The intent of the incentive is to promote use of the exchange.

A query is a query, regardless of whether information is available — A query still counts toward the incentive even when there is little or no information.

Multiple queries on the same patient on different dates are acceptable — Patient information may change.

The patient does not have to be a hospital or clinic patient — Any patient is eligible as long as the provider has a professional relationship with the patient and reason to query.

Your rep is here to help — For help with QBRP related to KHIE, contact your professional relations representative or provider network services in Topeka at (785) 291-4135 or (800) 432-3587.

QUICK TIPS: USING KHIE FOR GROUP B PROVIDERS ...

Aggregate requests datesGroups wanting to report by the aggregate method

must submit requests to BCBSKS in writing according to the following table:Request for Aggregate Aggregate Incentive Reporting by: Reporting begins: Nov. 1, 2015 Jan. 1, 2016 Feb. 1, 2016 March 1, 2016 May 1, 2016 June 1, 2016 Aug. 1, 2016 Sept. 1, 2016 Nov. 1, 2016 Dec. 1, 2016

[email protected]


RURAL ACCESS COUNTIES ...The following is a list of counties with a population of 13,000 or less that qualify for a Rural Access incentive.

County PopulationAnderson 7,917

Barber 4,861Brown 9,881Chase 2,757

Chautauqua 3,571Cheyenne 2,678

Clark 2,181Clay 8,531

Cloud 9,397Coffey 8,502

Comanche 1,913Decatur 2,871

Doniphan 7,864Edwards 2,979

Elk 2,720Ellsworth 6,494

Gove 2,729Graham 2,578Grant 7,923Gray 6,030

Greeley 1,298Greenwood 6,454

Hamilton 2,639Harper 5,911Haskell 4,256

Hodgeman 1,963Jewell 3,046Kearny 3,968

Kingman 7,863Kiowa 2,496Lane 1,704

Lincoln 3,174Linn 9,441

Logan 2,784

County PopulationMarion 12,347

Marshall 10,022Meade 4,396Mitchell 6,355Morris 5,854Morton 3,169

Nemaha 10,132Ness 3,068

Norton 5,612Osborne 3,806Ottawa 6,072Pawnee 6,928Phillips 5,519Pratt 9,728

Rawlins 2,560Republic 4,858

Rice 9,985Rooks 5,223Rush 3,220

Russell 6,946Scott 4,937

Sheridan 2,538Sherman 6,113

Smith 3,765Stafford 4,358Stanton 2,175Stevens 5,756Thomas 7,941Trego 2,986

Wabaunsee 7,039Wallace 1,517

Washington 5,758Wichita 2,256Wilson 9,105

Woodson 3,278

An Independent Licensee of the Blue Cross Blue Shield Association.

2016 BCBSKS CAP Summary (04/01/2015) FINAL Contains Confidential Information Page 1

BLUE CROSS AND BLUE SHIELD OF KANSAS PROVIDER POLICIES AND PROCEDURES

SUMMARY OF CHANGES FOR 2016 Following is a summary of the changes to Blue Shield Policies and Procedures for 2016. The policy memos in their entirety will be available in the provider publications section of www.bcbsks.com in December 2015. NOTE: Changes in numbering because of insertion or deletion of sections are not identified. All items herein are identified by the numbering assigned in 2015 Policy Memos. Deleted wording is noted in brackets [italicized]. New verbiage is identified in bold.

Policy Memo Nos. 1-12 TABLE OF CONTENTS

• Added cover and a Table of Contents to each Policy Memo.

Policy Memo No. 1 INTRODUCTION

• Page 1: Removed verbiage to correctly reflect resources applicable to Policy Memo.

The purpose of Blue Cross and Blue Shield of Kansas, Inc. (BCBSKS) Policies and Procedures is to provide specific explanations for provisions contained within the contracting provider agreements. This information is intended to supplement and further clarify the reciprocal rights and contractual obligations contained within the contract and the policies established by BCBSKS when services are provided in our service area (the state of Kansas not including Johnson and Wyandotte counties). All existing and future policies and procedures published within BCBSKS publications that are available via the BCBSKS website are considered part of the applicable Policy Memo. These publications include newsletters, provider manuals, [workshop materials, ]and periodic update communications. In the event provisions of such BCBSKS publications, policy memos, and/or the provider agreement conflict, the most recently published provision controls.

Policy Memo No. 1 SECTION I. CORRECTED CLAIM

• Page 2: Changed verbiage for clarity regarding corrected claims.

A request made from a contracting provider to change a claim, (e.g., changing information on the service line, modifier addition, diagnosis correction, etc.) that has previously processed is considered a corrected claim. The submission of a corrected claim must be received by BCBSKS within the 15-month timely filing deadline. [This excludes claims denied for additional information.] Claims denied requesting additional information (e.g. by

http://www.bcbsks.com/


letter or adjustment reason code) should never be marked "corrected claim" when resubmitted. Instead, providers should submit a new claim with the requested information.

Policy Memo No. 1 SECTION IV. POST-PAYMENT AUDITS

• Page 4: Added verbiage to clarify where to submit appeals.

A. First-Level Appeal

Services denied not medically necessary as a part of the post-pay audit process may be appealed in writing within 30 days of notification of the findings. Written notification of disagreement highlighting specific points for reconsideration should be provided with the appeal. The BCBSKS determination will be made within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

B. Second-Level Appeal

A provider may request a second and final appeal in writing within 30 days of notification of the first-level appeal determination. The second and final appeal determination will be made by a physician or clinical peer within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

Policy Memo No. 1 SECTION XI. MEDICAL RECORDS

• Page 10: Added verbiage to include total time.

g. List start and stop times or total time for each CPT code/service performed on all timed codes

per CPT nomenclature.

Policy Memo No. 1 SECTION XX. CONTRACTING STATUS DETERMINATION

• Pages 16-17: Rearranged language to better reflect purpose.

C. If the name of the provider set forth in the first paragraph of the contracting provider agreement is a

professional association or other legal entity, rather than that of an individual, then the contracting provider agreement applies to all persons within the professional association. Any new providers who join the professional association will be understood to be bound by the contracting provider agreement. The party signing the contracting provider agreement on behalf of the professional association warrants to BCBSKS that such party: (1) has the authority to sign such agreement on behalf of the professional association; (2) shall make the terms of the agreement known to members of the professional association; and (3) shall inform new members of the professional association of the terms of the agreement upon entry into the professional association. The foregoing warranties apply to any person defined as an eligible provider in


BCBSKS contracts employed by the individual, professional association or other entity signing the contracting provider agreement. If such eligible provider is among those identified in Section XXV. TIERED REIMBURSEMENT AND PROVIDER NUMBER REQUIREMENTS hereof, the MAPs applicable to such eligible providers will apply to any services provided by them. If such persons are contracting separately with BCBSKS, until such contract is terminated, then it shall apply rather than these provisions, but if such separate contract terminates, then nonetheless these provisions shall apply with regard to the contracting status of such person. NOTE: In the event a provider has been terminated by BCBSKS from the network and subsequently joins a participating provider’s practice, such participating provider will place his/her BCBSKS participating agreement in jeopardy (subject to termination for cause). Certain contracts offered by BCBSKS may offer individual physician options on contract status. Such options are specified by contract language and are offered solely at the discretion of BCBSKS. [The foregoing warranties apply to any person defined as an eligible provider in BCBSKS contracts employed by the individual, professional association or other entity signing the contracting provider agreement. If such eligible provider is among those identified in Section XXV. TIERED REIMBURSEMENT AND PROVIDER NUMBER REQUIREMENTS hereof, the MAPs applicable to such eligible providers will apply to any services provided by them. If such persons are contracting separately with BCBSKS, until such contract is terminated, then it shall apply rather than these provisions, but if such separate contract terminates, then nonetheless these provisions shall apply with regard to the contracting status of such person.]

D. It is the responsibility of the contracting provider or a representative to notify BCBSKS of any changes in practice information, e.g., license status, address, tax ID number, NPI, ownership, individual provider leaving/joining group practice, death of provider, closure of office, etc.

Policy Memo No. 4 SECTION VII. CREDENTIALING

• Pages 3-4: Rewrote section to better explain the credentialing process.

[BCBSKS has a credentialing program that consists of the initial full review of the provider's credentialing application and recredentialed at a minimum of every 36 months. Monitoring of all network providers for continual compliance with established criteria will occur as needed, but not less than monthly. If a provider ceases to comply with criteria or has actions taken by the licensing board (e.g. any agreement entered into with the appropriate licensing board), credentialing staff will review all adverse action and report to the Corporate Credentials Committee. If a provider's license has been suspended or revoked, action will be taken immediately to cancel their contract. Credentialing criteria are available on the BCBSKS website at: http://www.bcbsks.com/CustomerService/Providers/Publications/professional/PolicyMemos/credentialing-criteria.htm] A. [Initial/Recredentialing Applicant] Overview

1. Before a health care provider is eligible to become a contracting provider in the BCBSKS network, he/she must apply for and be granted credentialing status through the BCBSKS credentialing process as more fully described in the Credentialing Program Plan Description and BCBSKS policies and procedures (collectively, Program).

2. For providers who are not currently credentialed, he/she must submit application and undergo a

full review as described in the Program. For providers who are currently credentialed, they must undergo the recredentialing process described in the Program at least every 36 months.

http://www.bcbsks.com/CustomerService/Providers/Publications/professional/PolicyMemos/credentialing-criteria.htmhttp://www.bcbsks.com/CustomerService/Providers/Publications/professional/PolicyMemos/credentialing-criteria.htm


3. BCBSKS will monitor all network providers for continual compliance with established criteria as

needed but at least monthly. If any derogatory information is identified during monthly monitoring, credentialing staff will report such findings to the Committee that will follow the process outlined below.

[The BCBSKS Corporate Credentials Committee (Committee) reviews each provider’s credentialing file in accordance with BCBSKS criteria, as well as BCBSKS and URAC standards. If a provider does not meet these standards or there is evidence that he/she does not adhere to BCBSKS policies and procedures, the Committee may deny or restrict participation in a BCBSKS network. If the provider disagrees with the denial or restriction and has additional information, he/she may request reconsideration by the Committee. In the absence of additional information, the provider may submit a written request for a first-level appeal.]

B. [Reconsideration]Initial Consideration by BCBSKS Credentialing Committee

1. In order for an applicant to be considered for credentialing by the Committee, he/she must meet all applicable criteria as set out in the Program and that are available on the BCBSKS website*. An applicant who does not meet all applicable criteria may not be considered by the Committee. The reconsideration and appeal process described below is not available to applicants who do not meet all applicable criteria. *Credentialing criteria are available on the BCBSKS website at http://www.bcbsks.com/CustomerService/Providers/Publications/professional/PolicyMemos/credentialing-criteria.htm

2. The Committee reviews each provider’s credentialing file in accordance with BCBSKS criteria

and URAC standards. If a provider does not meet these standards or there is evidence that he/she does not adhere to BCBSKS policies and procedures, the Committee may deny or restrict participation in a BCBSKS network. If the provider disagrees with the denial or restriction and has additional information, he/she may request reconsideration by the Committee. In the absence of additional information, the provider may submit a written request for a first-level appeal within 30 calendar days of the date BCBSKS sends notice of the denial or restriction to the provider.

[If the Committee denies or restricts a provider’s participation status, the Committee will allow the provider to submit additional supporting documentation for reconsideration. If the denial or restriction is upheld by the Committee, the provider may submit a written request for a first-level appeal.]

C. Suspension for Member Safety BCBSKS will review any action taken against a contracting provider where the[re is] provider has committed unacceptable conduct or has allegedly exhibited behavior causing competency concerns or where there is concern for the safety of BCBSKS members. The contracting provider will be offered appeal rights if his/her contracting status is suspended.

D. [First-Level Appeal Panel]Circumstances When Reconsideration/Appeal is not Available 1. If the Committee denies or cancels credentialed status for a provider because of one or more of

the following reasons, the reconsideration and appeal process described below in Subsections E through G will not be available to such provider. a. Provider's professional license is not at full clinical scope of practice; b. Adverse action against the provider's DEA registration;

c. Provider is unable to supply credentialing staff with documentation of successful completion

of at least three years post-graduate training or equivalent work experience; or d. Provider is currently subject to any sanctions imposed by any CMS program or by the


Federal Employee Health Benefit Program, including but not limited to being excluded, suspended, or otherwise ineligible to participate in any state or federal health care program.

2. If a provider's regulatory board suspends or revokes his/her license, that provider's BCBSKS network contract is canceled by operation of the terms of the contract. When credentialing staff members become aware of such suspension or revocation, they shall notify the Committee, but the Committee is not required to take any specific action since the provider's contract will terminate of its own accord. Credentialing staff shall also notify the appropriate internal departments of such suspension or revocation to ensure that appropriate administrative action is taken.

[All appealed disputes are referred to a first-level appeal panel consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute. BCBSKS will have 60 days from receipt of the first-level appeal request to organize a first-level appeal panel.]

E. [Second-Level Appeal Panel]Reconsideration If the Committee denies or restricts a provider’s participation status, the Committee will allow the provider to submit additional supporting documentation for reconsideration. If the denial or restriction is upheld by the Committee, the provider may submit a written request for a first-level appeal within 30 calendar days of the date BCBSKS sends notice of the denial or restriction to the provider.[If the first-level appeal panel upholds the denial or restriction, the provider may submit a written request for a second-level appeal. This provides consideration to a second-level appeal panel consisting of at least three individuals as defined in the first-level appeal panel and that were not involved with the first-level appeal panel. BCBSKS will have 60 days from receipt of the second-level appeal request to organize a second-level appeal panel.]

F. First-Level Appeal Panel

All appealed disputes are referred to a first-level appeal panel consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the provider that filed the dispute. BCBSKS will have 60 days from receipt of the first-level appeal request to convene a first-level appeal panel.

G. Second-Level Appeal Panel If the first-level appeal panel upholds the denial or restriction, the provider may submit a written request for a second-level appeal. BCBSKS will convene a second-level three-member appeal panel consisting of at least one member who must be a contracting provider not otherwise involved in network management and who is a clinical peer of the provider who filed the dispute. None of the second-level panel may have been members of the first-level appeal panel. BCBSKS will have 60 days from receipt of the second-level appeal request to convene a second-level appeal panel.

H. Second-Level Appeal Panel Decision The result of the appeals process shall be binding on both the provider and BCBSKS subject only to the provision for binding arbitration previously stated in Policy Memo No. 1. For every provider whose denial or cancelation of credentialing status is upheld, credentialing staff will report the decision to the provider's regulatory board and the National Practitioner Data Bank.


Policy Memo No. 11 SECTION II. ENDOSCOPIES, ARTHROSCOPIES, AND OTHER

SCOPE PROCEDURES

• Page 1: Corrected MAP reference to RVU. For two or more surgical scope procedures that involve multiple compartments or sections of the same anatomic area (including but not limited to joints, sinuses, and abdominal, chest, pelvic, and cranial cavities), only the procedure with the highest [BCBSKS MAP] RVU will be reimbursed; other procedures shall be considered content of service. Exceptions based on unusual clinical intensity and/or use of physician resources are also available on a claim-by-claim basis; such claims will only be considered for additional reimbursement if Modifier 22 and appropriate supporting records are submitted with the original claim.

2016 contracting professional relations cap report · 2020. 11. 2. · cap 4 note — in 2016, for...

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