HOSPITAL QUADRANT MEETINGS AUGUST 2015
AGENDA Introduction Provider Certifications and Expanded Services Website Updates Other Party Liability (OPL) and Reconciling Accounts ICD-10 Edits VAPC3 and VACAA (Veterans Choice Program) 2016 Policies & Procedures Quality-Based Reimbursement Program (QBRP) Claims Pricing Q & A
Provider Certifications & Expanded Services The Contracting Provider agrees to notify BCBSKS of the addition of new services or the expansion of existing services. The purpose of this notification is to allow BCBSKS to determine if the new or expanded service is covered under the terms of the various member contracts. BCBSKS tracks the following types of provider certifications and services: • Diabetic Education • Lactation Consultant/Counseling • Blue Distinction Centers • Outpatient Pulmonary Rehabilitation • Cardiac Rehabilitation • Inpatient Hospice Programs • Sleep Studies • PET Scans
Provider Certifications & Expanded Services Diabetic Education • Outpatient diabetic education programs deemed appropriate for the educational requirements necessary to promote self-education toward a safe-and-healthy lifestyle for diabetic members may be eligible for coverage. • BCBSKS maintains a list and reimburses providers for diabetic education with one of the following: A program certified by the American Diabetes Association (ADA) A program certified by the American Association of Diabetes Educators (AADE) Employs a Certified Diabetic Educator (CDE). • Providers who are certified need to submit a copy of the certification to: BCBSKS Institutional Relations, cc442D2 1133 SW Topeka Blvd Topeka, KS 66629-001 Fax – 785-290-0734
Provider Certifications & Expanded Services Lactation Consultant/Counseling • Affordable Care Act (ACA) allows for coverage of these services under policies that have preventive benefit services related to breast feeding education and coaching. • Provide BCBSKS with a copy of the certification of the person performing the service received from either: Academy of Lactation Policy and Practice (ALPP) International Board of Certified Lactation Consultant (IBCLC) • Providers who are certified need to submit a copy of the certification to: BCBSKS Institutional Relations, cc442D2 1133 SW Topeka Blvd Topeka, KS 66629-001 Fax – 785-290-0734
Provider Certifications & Expanded Services Blue Distinction Center (BDC) Program The Blue Distinction Specialty Care Program is a national designation program through the Blue Cross and Blue Shield Association and the local Blue Plan that recognizes healthcare facilities that demonstrate expertise in delivering quality specialty care — safely, effectively, and cost efficiently through two levels of designation: • Blue Distinction Center (BDC) • Blue Distinction Center Plus (BDC+) Only those facilities that first meet nationally established, objective quality measures for BDC (quality only) will be considered for designation as a BDC+ (quality and cost).
Provider Certifications & Expanded Services Blue Distinction Center (BDC) Program Blue Distinction Center and Blue Distinction Center+ designations recognize healthcare facilities delivering the following types of specialty care: • Bariatric Surgery • Cardiac Care • Complex and Rare Cancers • Knee and Hip Replacement • Maternity Care -- Coming in 2016 • Spine Surgery • Transplants
Provider Certifications & Expanded Services Blue Distinction Center (BDC) Program There are many benefits of becoming a Blue Distinction Center or Blue Distinction Center+, including: • Differentiation in your community and beyond • Enhanced awareness and preference • Recognition among employers • Benchmarks provided to evaluate your performance against your peers Please contact your BCBSKS Institutional Provider Consultant for more details on BDC Programs. BDC information for providers can be found on the following web page: http://www.bcbs.com/healthcare-partners/blue- distinction-for-providers/
Provider Certifications & Expanded Services Outpatient Pulmonary Rehabilitation BCBSKS offers coverage for pulmonary rehabilitation programs and coverage is determined by: • the individual member’s contract • referral by their attending physician • BCBSKS Medical Policy – Outpatient Pulmonary Rehabilitation Program. Providers should submit a detailed program description which must include: • A program schedule that includes date/times service is offered • A description of the services and equipment available • A description of the staff providing the services • A notation of physician availability • What criteria is used for patient assessment • A charge structure
Provider Certifications & Expanded Services Outpatient Pulmonary Rehabilitation BCBSKS must also receive a signed attestation certifying the facility’s understanding and compliance with the criteria. Programs will normally be considered approved the first of the month following receipt of the attestation and supporting documents. Members will receive eligible benefits for pulmonary rehabilitation programs that begin on or after the approval date . BCBSKS reimbursement is based on a maximum allowable payment (MAP) for each day of client participation. Detailed information on the Outpatient Pulmonary Rehabilitation Program can be found in the BCBSKS Institutional Provider Manual on BlueAccess
Provider Certifications & Expanded Services Cardiac Rehabilitation BCBSKS offers coverage for cardiac rehabilitation programs and coverage is determined by: • The individual member’s contract • BCBSKS Medical Policy – Cardiac Rehabilitation Programs Providers should submit a detailed program description which must include: • A program schedule that includes date/times the service is offered • A description of the services and equipment available • A description of the staff providing the services • A notation of physician availability • What criteria is used for patient assessment • A charge structure
Provider Certifications & Expanded Services Cardiac Rehabilitation BCBSKS must also receive a signed attestation certifying the facility’s understanding and compliance with the criteria. Programs will normally be considered approved the first of the month following receipt of the attestation and supporting documents. Members will receive eligible benefits for pulmonary rehabilitation programs that begin on or after the approval date . Claims for cardiac rehabilitation should be submitted with Revenue Code 0943 and either CPT code 93797 or 93798 and report 1 unit for each day the patient participated in rehabilitation during the billing period. Detailed information on the Cardiac Rehabilitation Program can be found in the BCBSKS Institutional Provider Manual on BlueAccess
Provider Certifications & Expanded Services Inpatient Hospice Inpatient hospice services provided in a skilled nursing facility, hospital or other inpatient facility must be outlined and approved under the BCBSKS hospice inpatient program. The allowance for approved inpatient hospice services will be 110% of the provider's Medicare inpatient hospice rate Inpatient hospice services must be prior authorized The reimbursement guidelines for inpatient hospice services include: • Services are provided in the skilled nursing facility, hospital or other inpatient facility approved under the hospice inpatient program. • Members cannot be billed separately for room and board. • If the member has an inpatient skilled nursing facility benefit in addition to their hospice benefit, only the hospice benefit will be payable when the member has elected hospice coverage. • Revenue Code – 0656 – Inpatient Hospice Services
Provider Certifications & Expanded Services Inpatient Hospice If Total Parenteral Nutrition (TPN) is approved for an inpatient hospice patient, then TPN is part of the inpatient hospice per diem and is not billed separately by the hospice provider. Hospice providers are responsible for providing written notice to BCBSKS when their Medicare per diem rates are updated. Rates can be sent to: BCBSKS Institutional Relations Department, cc442D2 1133 SW Topeka Blvd. Topeka, KS 66629-0001 Fax: 785-290-0734
Provider Certifications & Expanded Services Sleep Studies BCBSKS encourages sleep study facilities to become an accredited sleep study facility. Contracting providers receive higher reimbursement if they are accredited, but providers who qualify for the highest level of reimbursement must notify BCBSKS in advance of billing claims. Proof of the accreditation must be submitted in order to receive proper reimbursement. BCBSKS recognizes the following accreditation for sleep studies: • American Academy of Sleep Medicine (AASM) • Accreditation Commission for Health Care, Inc (ACHC) When accreditation is received, send the information to: BCBSKS Institutional Relations Department, cc442D2 1133 SW Topeka Blvd. Topeka, KS 66629-0001 Fax: 785-290-0734
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