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N e w s l e t t e rProvider S u m m e r

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Review of Current Blue Cross of Idaho Partnerships and Provider Engagement/Education OpportunitiesBlue Cross of Idaho has partnered with ArroHealth to conduct a medical record review for individuals and small groups on Qualified Health Plans (QHP) to meet Affordable Care Act (ACA) requirements. This audit is designed to ensure that appropriate diagnosis codes are captured on claims submitted to Blue Cross of Idaho.

We are also working with Optum to conduct medical record reviews for the Medicare Advantage populations. These reviews ensure that diagnosis codes billed on claims are entered correctly and supported by medical records.

Blue Cross of Idaho also works with Optum on a Healthcare Quality Patient Assessment Form (HQPAF) program. This program obtains complete and accurate health status assignments for our Medicare Advantage Members, some of whom are your patients. The HQPAF is an assessment form that highlights current and suspected gaps in care, medical history and current chronic illnesses.

Both ArroHealth and Optum are bound by all applicable federal and state privacy and confidentiality requirements while conducting the reviews on our behalf.

The Healthcare Effective and Data Information Set (HEDIS®) is an annual collection of data that assesses the status of health plans’ preventive health maintenance activity levels and allows health plans to compare data. HEDIS® provides data for quality improvement programs and processes.

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage (MA) plans and Qualified Health Plans with marketplace products to participate in the annual HEDIS audit. Each year from January through mid-May, a representative from the Blue Cross of Idaho Healthcare Operations Department will send you a list of the medical records for review, as well the measures requiring review. A Blue Cross of Idaho representative may come to your office to review and extract required information. The data is audited per CMS requirements, and therefore providers may be requested to provide copies of some medical records that support abstracted information.

CMS deployed its Star rating system that rates a health plan’s MA programs. Star ratings are awarded based on 53 quality measures across eight topics. Each measure falls into member-centric categories focusing on areas such as managing long-term conditions, preventive care, member experiences with drug plans and customer service/plan responsiveness. Health plans are awarded a number of stars ranging from one (poor compliance) to five (excellent compliance) based on performance in the quality measures

To better serve our providers, Blue Cross of Idaho has created a new position – provider engagement and education representative – to work with external partners and assist with conducting HEDIS. These specialists will work in partnership

with the Provider Network Management, Risk Score Management and Healthcare Operations departments, to raise awareness among providers and their staffs of referral patterns, gaps in care, billing, as well as coding and documentation to appropriately report member healthcare conditions.

Provider engagement and education representatives will serve as liaisons and maintain communication between Blue Cross of Idaho and the providers regarding company policies and payment procedures. They also facilitate proper claim submission, provide contracting information for all lines of business and identify potential problem areas. Blue Cross of Idaho will soon be posting links to educational opportunities and resources on our provider website, providers.bcidaho.com, including Optum Coding Classes offering CEUs, coding examples, clinical documentation improvement (CDI) content, optimal electronic medical record (EMR) code searches and simplified quality reporting information.

The new provider engagement and education representatives are:Angie McCormick, CPC, CPC-P, CRC

Angie.McCormick@bcidaho.com

Kathy Brock, CPC-P Kathy.Brock@bcidaho.com

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monthly medical Focus Through our partnership with Optum, Blue Cross of Idaho servicing providers and staff can access a variety of free tools and code training opportunities with many offering AAPC CEU’s. Optum provides a monthly focus that concentrates on a medical topic each month. The monthly articles and information resources are posted to our provider website, providers.bcidaho.com. Select Forms and Resources, then Provider Risk and Audit Education.

Upcoming medical topics are:

• August: Eye diseases

• September: Hematologic disorders

• October: Breast cancer

reminder – Healthcare Quality Patient Assessment Form (HQPAF)/Patient Assessment Form (PAF) ProgramsThe Healthcare Quality Patient Assessment Form (HQPAF) and Patient Assessment Form (PAF) programs promote early detection and ongoing assessment of chronic conditions for our Medicare Advantage members. The goal of the program is to help ensure patients receive a complete and comprehensive annual assessment.

During the assessment, all conditions, including all acute and chronic conditions, should be evaluated and documented in the patient’s chart to the highest level of certainty or specificity. Routine exams and screenings can help identify and detect chronic conditions, often before the patient has any symptoms. These annual assessments are an important part of maintaining the quality of care and the quality of life of your patients.

In addition to receiving an annual assessment, the PAF/HQPAF program supports a variety of the Centers for Medicare and Medicaid Services (CMS) programs, including the Healthcare Effectiveness Data and Information Set (HEDIS) and the Five-Star Quality Rating System.

Optum administers the program on behalf of Blue Cross of Idaho, and there is a monetary incentive to return the forms. The administrative reimbursement rate will be determined by the timeliness of submission of the PAF/HQPAF back to Optum. Forms received within 60 days of the date of service (DOS), receive full administrative reimbursement. Forms received beyond 60 days of the DOS, receive a reduced administrative reimbursement.

Optum can assist providers with these programs that encourage patients to schedule an annual assessment with your practice. These programs may include, call campaigns to patients to remind them to see their providers annually, assistance making an appointment and materials that help educate patients on chronic conditions and the importance of maintaining their health.

Member Search Website EnhancementThe member search application on the secure provider portal, providers.bcidaho.com, now displays more detailed information, including a patient’s product type (Connected Care Saint Alphonsus, Connected Care Portneuf, PPO etc.).

To find the search tool:

Log in with your username and password

Select Eligibility & Claims

Select Member Search

Enter in the required fields and select Search

Select the desired patient. The product

type will display under Coverage Information

Step

1Step

2Step

3Step

4Step

5

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Diabetic Supplier Withdraws from NetworkDiabetic supplier Dexcom withdrew from our provider network earlier this summer. This was not an easy decision for Dexcom, and we appreciate our seven-year relationship with them.

Dexcom provides continuous glucose monitors and other diabetic supplies. If you have patients currently using Dexcom products, we encourage you to talk with them about their options for diabetic supplies. You have until September 30, 2016, to help your patients find a new diabetic supplier and obtain a new prior authorization to continue receiving their diabetic supplies without interruption.

The following in-network distributors have confirmed they are providers for Dexcom products, including continuous glucose monitors:

• Advanced Diabetes Supply: 866-422-4866

• Better Living Now: 800-854-5729

• CCS Medical: 800-726-9811

• Edgepark Surgical: 800-321-0591

• Liberty Medical Supply: 866-896-7307

Please feel free to contact your Provider Relations representative with any questions.

Preventive Care for Adolescents an Important ToolAccording to the American Academy of Pediatrics, only two out of three adolescents go to their primary care provider every year, and only one out of 15 visits is for preventive care. Unfortunately, studies show that the percentage of preventive care visits among adolescents decreases as they enter adulthood. While preventive care is important in all stages of life, wellness exams can give adolescents the tools they need to help them make healthy choices and give them a voice about their own body.

Topics of conversation:

Body image• Questions or concerns they may have.

• Healthy eating

• Staying active and avoiding long hours of television and electronics

Social history• Do they have good relationships with family, friends

and at school?

• Do they have a good support system?

Mental health status• How do they deal with stress?

• Are they experiencing depression or anxiety?

• Have they had any suicidal thoughts or tendencies?

• Are they dealing with bullying or cyberbullying?

Risky behavior • Do they use alcohol, drugs, tobacco or are vaping?

• Are they sexually active?

• Do they take precautions against STDs?

Injury prevention• Do they always wear their seatbelt?

• Do they wear protective gear for sporting activities?

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BlueCard Alpha Prefix ToolBlue Cross of Idaho’s BlueCard Alpha Prefix tool helps determine which plan should receive a medical claim when you provide services to BlueCard (out-of-area) or Federal Employee Plan (FEP)member(s).

Providers can select a specific service date to return information on the member. Once you enter the member’s prefix and service date, the results will include:

• Plan code – the out-of-state plan number of the group

• Plan name – the name of the insurance plan

• Account name – the name of the group the insured belongs to

• Effective date and termination date – start and end date of the group coverage

• Prefix end date – this is the last date that any claim can be accepted for processing

The tool displays remarks related to the specific prefix and service date inquiries, such as invalid prefix, subscriber ID or date of service and allows inquiries for FEP members and directs providers where to submit either professional or facility medical claims.

This tool can be accessed by logging in to the provider portal with your user name and password. Select Eligibility & Claims, then Alpha Prefix to view the tool. If you need help, you can take advantage of an instructional video, as well as printable instructions.

If you have additional questions, you can contact your Provider Relations representative. You can find contact information at providers.bcidaho.com by selecting Contact at the top of the page and then Provider Relations.

Saving Lives from Colorectal Cancer

Idaho’s 80 Percent by 2018 InitiativeThe American Cancer Society (ACS), Centers for Disease Control and Prevention (CDC) and the National Colorectal Cancer Roundtable are introducing the 80% by 2018 Colorectal Cancer Screening initiative. Their goal is to have 80 percent of adults age 50 and older screened for colorectal cancer by 2018. To learn more on how to help Idaho reach 80 percent by 2018 visit:

• cancer.dhw.idaho.gov

• ccaidaho.org

• nccrt.org

Direct Claims entry TipsAs of April 1, 2016, Blue Cross of Idaho no longer accepts paper CMS 1500 claims from contracting medical providers. We are excited to offer a tool on the secure provider portal at providers.bcidaho.com, to assist with electronic claim submission.

The Direct Claims Entry (DCE) tool can be used to attach medical records, invoice copies, coordination of benefit information or any documents needed to submit with a claim.

A Primary Explanation of Benefits (PEOB) is required when submitting secondary claims through the DCE. Along with the PEOB, a source of payment code is required in the “Additional Claim Information” box provided. You can use this box to list other additional claim information, including an original claim number.

For more information regarding source of payment codes, please review Provider Administrative Policy 234.

2017 Open enrollmentThe open enrollment period for 2017 healthcare coverage runs November 1, 2016, through January 31, 2017. Anyone who does not enroll in a qualified healthcare plan (QHP) during this time will not be able to enroll in one in 2017 unless he or she has a qualifying special enrollment period (SEP) event. Your Health Idaho (YHI), the Idaho health insurance exchange, provides information and resources – including a glossary of terms, frequently asked questions, and an explanation of what events qualify for a SEP. Providers can review this information at yourhealthidaho.org.

Once 2017 policies become active, please keep in mind that patient information may need to be updated. Deductible accumulations, member ID cards, benefits and prior authorization requirements may have changed. Patient information can be verified by logging in to the secure provider portal at providers.bcidaho.com.

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Risk Chart AuditsWhat to Report, What to ExpectRisk adjustment is a component of healthcare reform designed to improve coverage, preserve consumer choice and improve the quality of care for patients. Medicare risk adjustment is administered by the Centers for Medicare and Medicaid Services (CMS) and payments are made to Medicare Advantage plans.

For commercial risk adjustment, either the state or federal government (Department of Health and Human Services (HHS)) is responsible for operating risk-adjustment models. These models redistribute money from health plans with healthier populations to those with sicker patient populations.

Both risk adjustment models assess health plans by their amount of risk, and help align payments to the plans, taking into account the risk characteristics of those enrolled in each. Health plans are either paid, or pay out, based on the risk associated with their individual or small group enrollees.

Accurate risk adjustment relies on comprehensive, face-to-face health assessments of patients. Medical record documentation is necessary to record facts, findings and observations about an individual’s health history. These include past and present illnesses, exams, tests, treatments and outcomes. Physicians need to accurately document medical records and coding practices to capture the complete risk profile of each patient. The diagnosis codes submitted on a claim are used to determine the level of risk associated with the patient. Because of this, the provider has a pivotal role in substantiating risk payment amounts.

Risk chart audits are conducted periodically to verify that diagnostic information is in the medical record. The primary purpose of these audits is to verify that the patients’ health status and that the diagnoses are accurately captured and reported. The reviews ensure compliance with CMS and HHS Risk Adjustment Data Validation (RADV)

requirements by verifying diagnosis codes previously submitted via claims data.

We recommend that you put “MEAT” in your documentation. M.E.A.T. is an acronym for:

M – Monitoring

E – Evaluating

A – Assessing/addressing

T – Treatment

Auditors check medical record documentation to ensure it includes monitoring, including the signs and/or symptoms and disease progression or regression and if an evaluation was performed listing test results, medication effectiveness and the patient’s response to treatment. Auditors also verify if an assessment was performed in regards to ordering necessary tests, discussion with the patient, review of records and counseling, if needed. Treatment information should also be documented, including medications, therapies and other modalities, etc.

Your office may receive a request to provide medical records as part of a risk chart audit, and your provider contract requires cooperation with these requests. Your office should anticipate a call from one of our vendors to coordinate the retrieval of the medical records. You will get retrieval details and a specific list of members who are part of the risk chart audit. To the right are common items needed to be submitted to conduct a thorough risk chart audit.

Physician

• Progress Notes (face-to-face office visit)

• History and Physical Exam

• Consult Notes

• Problem List

• Signature Log Hospital

• Progress Notes

• Consultation Reports

• History and Physical Exam

• Emergency Room Records

It is critical that all dates of service be signed (with credentials) and dated by the provider (qualified provider is MD, PA, NP). You will need to provide a signature log, with qualifications (MD, PA, NP) to identify signatures of physicians, physician assistants, and nurse practitioners that appear within the paper medical record.

Directory updateComing Soon:

Updated Provider Directory available on the unsecure provider portal,

providers.bcidaho.com.

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Any Questions?

Medical Management

Managed Health Care/Review, Preadmission/Admission Certification, or Individual Benefits Management and Case Management■ 208-331-7535 ■ 800-743-1871 ■ Voice mail available after office hours and on holidays and weekends

Blue Cross of Idaho Help Desk

Electronic Billing Errors, Error and Acceptance Reports■ 8 a.m. – 5 p.m. MT (Monday – Friday), ■ 888-BCI-EDIA, 888-224-3341 or 208-331-8817

Provider Contact Center for Commercial and Medicare Advantage

Benefits, Coverage and Authorization ■ 8 a.m. – 5 p.m. MT (Monday, Tuesday, Thursday, Friday) 8:30 a.m. – 5 p.m. MT (Wednesday) ■ 208-286-3656 or 866-482-2250Post-service claim questions log onto our secure website at providers.bcidaho.com and select Contact Us.

Provider Relations Representative

Questions regarding coding, contracting or need website training, you may contact one of the following provider relations representatives. ■ 866-283-5723 or 208-286-3602

Ext. 8326: Leah Hulse CPC – Counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone

Ext. 8306: Jamie Hunihan – Counties: Adams, Boise, Canyon, Gem, Owyhee, Payette, Valley and Washington

Ext. 8304: Heidi Lowman – Cities: Boise and Meridian

Ext. 8310: Jenn Lucy, CPC – Counties: Bannock, Bear Lake, Bingham, Blaine, Bonneville, Butte, Camas, Caribou, Cassia, Clark, Custer, Franklin, Fremont, Gooding, Jefferson, Jerome, Lemhi, Lincoln, Madison, Minidoka, Oneida, Power and Teton

Ext. 9005: Kylee Williams – Cities: Eagle, Garden City, Kuna and Star. Counties: Elmore and Twin Falls