Delinquent payment indicator on NaviNet® for APTC membersLearn about a new field that informs providers when APTC members are delinquent in paying their premiums

Clarification: Mom/baby claims submission for FEP membersUnderstand how the mom/baby claims submission process differs for FEP members

Quick tips for a smooth out-of-area claims experienceUse these tips to improve your experience with out-of-area claims

Use a valid NPI for all claimsReview the requirement for providers to submit a valid NPI on all claims

Updated payer ID grids now available Download the updated payer ID grids for the most current information

2

S P R I N G 2 0 1 4www.ibx.com/providers

4

Provider financial responsibility for preapproval of inpatient facility services for out-of-area membersEffective July 1, 2014, participating providers will be responsible for obtaining preapproval for inpatient facility services for out-of-area members. Dates of admission on or after July 1, 2014, will be subject to this requirement, and the out-of-area member will be held harmless.

While most providers currently take responsibility for obtaining preapproval for inpatient facility services, this requirement will move financial responsibility from the member to the provider. Failure to obtain preapproval for inpatient facility services for out-of-area members will result in a denied claim. To avoid claim denials, it is important to preapprove the inpatient stay and check that additional days are authorized before an out-of-area member is discharged.

Denied days within an approved inpatient stayIf there are denied days within an approved inpatient stay, the provider will be financially liable for the denied days and the member will be held harmless. In diagnosis related group (DRG)/case rate situations, when the length of an inpatient stay extends beyond the preapproved length of stay, any additional days must be approved by the last day of the originally approved days.

Getting preapproval for out-of-area membersTo get preapproval of inpatient facility services for an out-of-area member, providers should call the BlueCard Eligibility® line at 1-800-676-BLUE and ask to be transferred to the utilization review area.

Note: We anticipate that IBC providers will be able to submit electronic preapproval requests for out-of-area members starting in mid-August. We will publish more information about this new capability in future editions of Inside IPP. v

INSIDE THIS EDITION

5

2www.ibx.com/providers

INSIDE IPP • SPRING 2014

2

Delinquent payment indicator on NaviNet® for APTC members

www.ibx.com/providers

The Advanced Premium Tax Credit (APTC) is part of the Patient Protection and Affordable Care Act, also known as Health Care Reform. The APTC helps qualifying individuals and families obtain health insurance by reducing monthly premiums. Health Care Reform mandates a three-month (i.e., 90-day) grace period for individual APTC members who are delinquent in paying their portion of the premiums.

Under the mandate, insurers are required to pay medical claims received during the first 30 days of the grace period, but they may pend medical claims for services rendered to those members and their eligible dependents during the second and third months of the grace period. If payment is not received by the end of the grace period, the pended claims will be denied and the member’s policy will be terminated.

Delinquent payment indicatorA new field, called APTC, has been added within the Eligibility and Benefits Details screen on the NaviNet® web portal to show providers when a patient is in the grace period and to provide a status of the member’s claims.

When an APTC member is delinquent on his or her monthly insurance premiums, the following will display on the Eligibility and Benefits Details screen: • APTC member indicator • current status, which includes:

− number of months that the member is delinquent − whether the insurance company will pay, suspend, or deny the member’s medical claims

Note: The APTC field will only display when an APTC member is in a delinquency status. continued on the next page

3www.ibx.com/providers

INSIDE IPP • SPRING 2014

If an APTC member’s claim is suspended due to a delinquent payment, the corresponding code and reason will also appear within the claim line in the Claims Status Inquiry transaction. Select Additional Details for an explanation of why the claim is not yet finalized.

For more information A user guide is now available to help you navigate information for APTC members and their current status if they have a delinquent payment. We encourage you to review this guide, which is published in the NaviNet Transaction Changes section of our Business Transformation site at www.ibx.com/pnc/businesstransformation.

If you have any questions about NaviNet transactions, please call the eBusiness Hotline at 215-640-7410. v

continued from the previous page

4www.ibx.com/providers

INSIDE IPP • SPRING 2014

As previously communicated, effective for dates of admission on and after November 1, 2013, mom/baby inpatient hospital claims must be submitted as separate claims — one for the mom and one for the baby. This change applies regardless of members’ migration status (i.e., whether the claim is processed on the new operating platform or on the existing platform), including local and Host BlueCard® claims. You will receive two separate Statements of Remittance (SOR) for mom/baby claims.*

Please note that this change does not apply to Federal Employee Program (FEP) members.

Mom/baby claims submission for FEP membersThe mom/baby claims submission process for FEP members is different. Please adhere to the following guidelines for FEP members: • A separate admission for the baby is needed only when and

if the baby requires a higher level of care and is considered sick while the mother is still hospitalized.

• The baby’s admission requires its own preapproval. • The baby’s claim should be billed using either revenue code

0173 or 0174 when the admission date is the same as the preapproval date.

This information was recently communicated in Bulletin #08-2014: FEP Clarification for Mom/Baby Claims Submission Process. Refer to this bulletin at www.ibx.com/bulletins for more information about submitting mom/baby claims. Please contact your Network Coordinator if you have any questions. v

*As of November 1, 2013, and continuing through mid-2015, IBC is in the process of migrating its membership to a new operating platform. Once a member has been migrated to the new platform, providers will no longer receive the current SOR. Professional providers will receive what will be called the Provider Explanation of Benefits (EOB). Once all members are migrated in 2015, you will only receive the new Provider EOB.

Clarification: Mom/baby claims submission for FEP members

4www.ibx.com/providers

Quick tips for a smooth out-of-area claims experienceDid you know that you can make a difference in how quickly your claims are processed? Follow these helpful tips to improve your experience with out-of-area claims: • When filing the claim, always submit the

member’s ID number exactly as it appears on their ID card, inclusive of the alpha prefix. The majority of Blue-branded ID cards have an alpha prefix in the first three positions of the member’s ID number, and it is critical for proper claims filing. It is also required for any inquiries regarding the member, such as eligibility and benefits.

• Ask members for their current ID card and regularly obtain new photocopies of it (front and back). Having the most current information helps to avoid unnecessary delays in payment.

• Prior to rendering services, verify eligibility and benefits using the BlueExchange® Out of Area transaction on the NaviNet® web portal or by calling 1-800-676-BLUE.

• Verify the member’s cost-sharing amount before processing payment. Indicate on the claim any payment you collected from the member.

• In cases where there is more than one payer and a Blue Plan is the primary payer, submit Other Party Liability information with the Blue claim. Upon receipt, IBC will electronically route the claim to the member’s Home Plan. The member’s plan then processes the claim and approves payment; IBC will reimburse you for services.

• Do not send duplicate claims. Sending another claim, or having your billing agency resubmit claims automatically, slows down the claims payment process and creates confusion for the member.

If you have any questions about claims filing for Blue members, call your Network Coordinator or refer to the BlueCard section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers. v

5www.ibx.com/providers

INSIDE IPP • SPRING 2014

Reminder!Additional resources

For BlueCard® facility claims, call 1-800-ASK-BLUE.

For questions about BlueCard eligibility, call the BlueCard Eligibility® line at 1-800-676-BLUE.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

The Blue Cross and Blue Shield names and symbols, BlueCard, BlueCard Eligibility, and BlueExchange are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

Inside IPP is a publication of Independence Blue Cross and its affiliates (IBC). Suggestions are welcome.

CONTACT INFORMATION

Provider Communications Independence Blue Cross 1901 Market Street, 27th floor Philadelphia, PA 19103

provider_communications@ibx.com

5

The payer ID grids contain valuable information to assist providers in claims submission.

The professional and facility payer ID grids have recently been updated to include a new alpha prefix for account-specific BlueCard® PPO members.

Please be sure to use the most current versions of the payer ID grids, which are available on our website at www.ibx.com/edi . v

Updated payer ID grids now available

www.ibx.com/providers

Use a valid NPI for all claimsAs previously communicated, when submitting claims for IBC members, please be sure to continue using a valid National Provider Identifier (NPI) for billing, rendering, and referring providers, as applicable.

This requirement applies to all claims — including those that are processed on our current and new operating platforms as we continue our transition of membership to the new claims processing system.

It is critical that you submit claims with a valid NPI, as the claims processing system reviews each claim for this data. Providers should work with their clearinghouse/trading partner to ensure accurate claims submission.

Using an invalid NPI could delay processing and payment.

The most common reasons that an NPI would be considered invalid are: • The NPI is terminated. • The NPI is entered incorrectly. • The number is invalid.

Resources For additional information about NPI regulations, implementations, reports, and resources, go to www.ibx.com/npi. For more information about our Business Transformation, please visit our dedicated site at www.ibx.com/pnc/businesstransformation. v