Name of Manual - Blue Cross and Blue Shield of Minnesota

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Guidelines for Determining Submissions to Medicare or Blue Cross Inquiries and Claims Platinum Blue (Cost) Health Care Options For services provided to Medicare members enrolled in our Medicare supplement or Platinum Blue plan that are eligible under Medicare Part A, Medicare is primary. CMS will continue to be the primary payor for these services with electronic claims crossing over from Medicare intermediaries. Blue Cross will serve as secondary payor for these services with members being subject to Medicare coinsurance and deductibles. Blue Cross is the administrator for Medicare Part B nonfacilitybased services and any additional Platinum Blue benefits. Reimbursement for professional providers utilize Blue Cross’ contracted fee schedule methodology. Current reimbursement uses 2005 RVUs with Medicare conversion factors and is GPCI adjusted (geographical adjustment). For the initial product launch, Medicare part B services will apply CCI edits at the claim level; as Blue Cross’ functionality evolves; auto adjudication will occur. To ensure CMS compliance, follow the guidelines outlined in standard Medicare bulletins and the Provider Policy and Procedure manual. For Medicare members enrolled in our Medicare Advantage plans, including MedicareBlue PPO, Blue Cross replaces Medicare as primary payor. Please see the information available on medical policy, claims submission and payment, etc at: http://www.yourmedicaresolutions.com/for_providers/ Provider claim and benefit inquiries for Platinum Blue can be directed to provider web self-service, BLUELINE or provider services at (651) 662-6500 or 1-800-262-0820. Care management inquires should be directed to (651) 662-5520 or 1-800-528-0934. Services eligible under Medicare part B and that would otherwise be billed to the Medicare carrier on a professional claims form/format, should be submitted directly to Blue Cross electronically, whenever possible. Group number for Platinum Blue individual members are: • Y0704 - C0 - Platinum Blue Core Option • Y0704 - C4 - Platinum Blue Core Option-Medicare B only members • Y0704 - H1 - Platinum Blue Core Option - Medicare Hospice enrolled members • Y0705 - C0 - Platinum Blue Choice Option Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 5-15
Health Care Options Inquiries and Claims Platinum Blue (Cost) (continued) • Y0705 - C4 - Platinum Blue Choice Option-Medicare B only members • Y0705 - H1 - Platinum Blue Choice Option - Medicare hospice enrolled members • Y0706 - C0 - Platinum Blue Complete Option • Y0706 - C4 - Platinum Blue Complete Option-Medicare B only members • Y0706 - H0 - Platinum Blue Complete Option - Medicare hospice enrolled members Please see the grid that follows for an overview of services, CMS billing format, and Medicare Part A or Part B eligibility. 5-16 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)
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Blue Cross and Blue Shield of Minne
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Recent Chapter changes: Chapter 11
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Chapter 11 - Coding Policies and Gu
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Durable Medical Equipment Date Topi
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Medical Emergency Date Topic Change
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Rehabilitative Services Date Topic
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Table of Contents Chapter 1 At Your
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Introduction Provider Policy and Pr
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How to Contact Us At Your Service P
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At Your Service Claims Address Subm
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Care Management Numbers and Address
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Care Management Numbers and Address
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Company Phone Number Address Public
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At Your Service Provider Identifica
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ID Cards At Your Service Introducti
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Electronic Commerce Overview An imp
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Remote Access Services (continued)
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Provider Communications Provider Co
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Health Plan Members have the Follow
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Provider Agreements Participation a
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Provider Agreements Responsibilitie
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Provider Agreements Provider Number
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Provider Agreements Accounting for
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Provider Agreements Carrier Replace
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Table of Contents Chapter 3 Quality
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Quality Improvement Leadership Rati
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Quality Improvement Telephone Care:
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Quality Improvement Quality of Care
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Quality Improvement Written Policie
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Quality Improvement Written Policie
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Quality Improvement Patient Safety
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Quality Improvement Medical Record
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Quality Improvement Institute for C
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Quality Improvement Quality Improve
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Quality Improvement Physical Facili
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Quality Improvement Treatment Recor
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Quality Improvement Treatment Recor
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Page 77 and 78: Integrated Health Management Progra
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Page 111 and 112: Integrated Health Management Sample
Page 113 and 114: Health Care Options Prepaid Medical
Page 115 and 116: Health Care Options Member ID Cards
Page 117 and 118: Health Care Options Blue Cross and
Page 119 and 120: Health Care Options Double Gold Dou
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Page 125: Health Care Options MedicareBlue PP
Page 129 and 130: Health Care Options Additional info
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Page 135 and 136: Health Care Options BlueLinkTPA Blu
Page 137 and 138: Health Care Options Delta Dental Hi
Page 139 and 140: Health Care Options Prime Therapeut
Page 141 and 142: Health Care Options Workers' Compen
Page 143 and 144: Health Care Options HICF 1500 Form
Page 145 and 146: Health Care Options Networks Blue C
Page 147 and 148: Blue Plus Member Information Introd
Page 149 and 150: Blue Plus Member Rights and Respons
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Page 153 and 154: Blue Plus Member Benefits Members
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Page 173 and 174: BlueCard® Claim Status Inquiry ...
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BlueCard® Identifying BlueCard ®
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BlueCard® BlueCard Service Claims
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BlueCard® Prior Authorization and
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BlueCard® Electronic Data Intercha
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BlueCard® Claims Processed by the
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BlueCard® Overview (continued) 3.
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BlueCard® Claim Payment Guidelines
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BlueCard® Calls from Members and O
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BlueCard® Guidelines (continued) W
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BlueCard® Types of Medicare Advant
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BlueCard® Medicare Advantage Claim
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BlueCard® Reimbursement for Medica
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Claims Filing HCPCS/ Accommodation
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Claims Filing Administrative Simpli
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Claims Filing Claims with Attachmen
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Claims Filing Claims with Coordinat
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Claims Filing Claims with Coordinat
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Claims Filing 1500 HICF Form Profes
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Claims Filing Ordering Forms and Ma
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Claims Filing Site of Service (cont
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Claims Filing Institution (837I) /F
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Claims Filing Treatment Room Blue C
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Claims Filing Single facility claim
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Claims Filing Present on Admission
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Claims Filing Medicare Crossover Bl
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Claims Filing Cancel/Void and Repla
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Claims Filing Verifying Patient Eli
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Claims Filing Basic Character Set V
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Claims Filing Rural Health Clinics
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Claims Filing Coordination of Benef
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Claims Filing TEFRA The 1982 Tax Eq
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Claims Filing Employment As defined
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Claims Filing Surgical Technicians
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Reimbursement / Reconciliation Reim
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Reimbursement / Reconciliation Comp
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Reimbursement / Reconciliation Remi
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Acco
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Reimbursement / Reconciliation Fiel
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Appeals Provider Appeals Introducti
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Appeals Submitting Requests for Pos
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Appeals Coding Appeals (continued)
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Appeals Supporting Documentation (c
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Coding Policies and Guidelines (Cod
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Coding Policies and Guidelines (Mod
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Chapter 11 Coding Policies and Guid
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Part-time (Medically Directed) Anes
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Electroconvulsive Treatments Blue C
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Moderate (Conscious) Sedation Monit
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Coding Policies and Guidelines (Beh
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Coding Restrictions Code Restrictio
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CTSS Skills Training and Developmen
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Intensive Residential Treatment Ser
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IRTS Member Eligibility IRTS Access
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Adult Non-Residential Crisis Servic
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MH-TCM Services to Minnesota Health
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Dialectical Behavioral Therapy/DBT
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Autism Spectrum Disorder/EIBI (cont
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Autism Spectrum Disorder/EIBI (cont
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Psychiatric Consultation to Primary
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Psychiatry and Chemical Dependency
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Medication Management M0064 and 908
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Nutritional Counseling/Medical Nutr
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Practitioner Key MD = Psychiatrist
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Clinical Supervision Under Minnesot
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DIAMOND Initiative (continued) Reim
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Missed Appointments (continued) Cou
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Guidelines for Court Ordered Evalua
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Guidelines for Court Ordered Evalua
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Behavioral Health Quality Improveme
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Pre-certification and Concurrent Re
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Coding Policies and Guidelines (Den
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Prior Authorization Requirements Co
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Coding Policies and Guidelines (Dur
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Waivers and Upgraded/Deluxe DME Wai
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Hearing Aids (continued) Website Co
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Portable Oxygen Billing (continued)
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DME/Supply Internet Purchases Codin
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Coding Policies and Guidelines (Hom
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Elderly Waiver Program (continued)
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Referrals and Prior Authorization (
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Referrals and Prior Authorization (
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Adult Day Care Bath Services Coding
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Home Infusion (continued) Coding Po
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Coding Policies and Guidelines (Hom
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Rules and Regulations (continued) H
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Hospice Billing for Medicare Produc
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Coding Policies and Guidelines (Hos
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Coding Policies and Guidelines (Lab
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Papanicolaou Smears (continued) Dia
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Coding Policies and Guidelines (Opt
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Coding Policies and Guidelines (Pha
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Drugs Coding Policies and Guideline
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Drug Programs Coding Policies and G
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Coding Policies and Guidelines (Pub
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Physical Therapy Evaluation Codes C
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Hot and Cold Pack Exclusion TMJ Ort
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Massage and Manual Therapy Exclusio
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MHCP PT, OT, ST Authorization Proce
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Bilateral Services (continued) Codi
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Coding Policies and Guidelines (Sur
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Acne Treatment/ Skin Rejuvenation a
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Liposuction Edit Change Coding Poli
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Assistant Surgeons (continued) Assi
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