Name of Manual - Blue Cross and Blue Shield of Minnesota

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Mental Health and Chemical Dependency Services Blue Plus Blue Plus members may coordinate their evaluation/management (E/M) or medication management services through their PCC or their designated behavioral health provider. E/M and medication management services performed outside of their PCC or designated behavioral health provider will require a referral from the member’s PCC in order to receive the highest level of benefits. Most groups do not require referrals for claims to process at the highest level. However, member contracts that require the member to stay in the Select behavioral health network would need authorization from Blue Plus to see a provider outside of that network. PCCs do not need to initiate referrals for patients requiring mental health/chemical dependency care. OB/GYN Services State legislation requires open access for specified ob/gyn services under managed care contracts. When a member obtains eligible ob/gyn services, she may go to her PCC or elect to seek care from any ob/gyn network provider without a referral from the PCC and receive the highest level of her benefits. This benefit is effective for fully-insured groups. This benefit is optional for self-insured groups. OB/GYN Open Access Additional Services • Eligible services: The member can go to any ob/gyn network provider for approved services. The approved services are considered services billed by a network ob/gyn with a diagnosis code on our approved list. (See the list later in this chapter.) If a member’s needs expand beyond the specified ob/gyn openaccess benefits, the member needs to be directed back to her designated PCC or be referred by her PCC in order for the care to be coordinated by the member’s PCC. For example, when the ob/gyn provider identifies ovarian cancer and the member needs to see an oncologist, the member should be directed back to her PCC, because the oncologist is not an ob/gyn provider. The open access benefit is only for services billed by ob/gyn providers. For those members who have an open access benefit, eligible inpatient and outpatient hospital and related ob/gyn services are covered at the member’s highest benefit level. An open access ob/gyn provider must coordinate the services. We may not be able to identify these claims during initial processing. Adjustments to claims may be requested electronically through provider web selfservice, or by calling Provider Service. Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-23
Blue Plus OB/GYN Open Access Diagnosis Please refer to the following list of designated ob/gyn open access diagnosis codes. Eligible claims submitted with these diagnosis codes from a specified ob/gyn network provider do not require a referral, if the patient has the ob/gyn open-access benefit. Code Description 054.0-054.19 Herpes simplex 078.81-078.89 Other diseases due to viruses and Chlamydiae 079.4 Hum an papillomavirus 079.81. 079.89 Other specified viral and chlamydial infections 099.0-099.9 Syphilis and other venereal disease 112.0-112.9 Candidiasis 127.4 Enterobiasis 131.00-131.9 Trichom oniasis 132.2 Phthirus pubis 174.0-184.9 Malignant neoplasm 217-221.9 Benign neoplasm 233.0-233.9 Carcinoma in situ of breast and genitourinary system 236.0-236.99 Neoplasm of uncertain behavior of genitourinary system 239.3 Neoplasm of unspecified nature of breast 239.5 Neoplasm of unspecified nature of other genitourinary organs 256.0-256.9 Ovarian dysfunction 599.0 Urinary tract infection, site not specified 610.0-611.9 Disorders of breast 614.0-616.9 Inflammatory disease of female pelvic organs 617.0-627.9 Other disorders of female genital tract, infertility 630-677 Complications of pregnancy, childbirth and the puerperium 698.1 Pruritus of genital organs 752.0-752.9 Congenital anomalies of genital organs 6-24 Blue Cross 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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Integrated Health Management Progra
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Integrated Health Management Provid
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Integrated Health Management Utiliz
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Integrated Health Management Medica
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Integrated Health Management Overvi
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Integrated Health Management Pre-Ce
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Integrated Health Management Decisi
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Integrated Health Management Defini
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Integrated Health Management For Lo
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Integrated Health Management Appeal
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Integrated Health Management Case &
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Integrated Health Management Diseas
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Integrated Health Management Focuse
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Integrated Health Management Specia
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Integrated Health Management Overvi
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Integrated Health Management Sample
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Health Care Options Prepaid Medical
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Health Care Options Member ID Cards
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Page 123 and 124: Health Care Options Platinum Blue S
Page 125 and 126: Health Care Options MedicareBlue PP
Page 127 and 128: Health Care Options Inquiries and C
Page 129 and 130: Health Care Options Additional info
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Page 135 and 136: Health Care Options BlueLinkTPA Blu
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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 157 and 158: Blue Plus Referral Points Remember
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Page 161 and 162: Blue Plus Standing Referral Minneso
Page 163 and 164: Blue Plus Clarifications of Terms (
Page 165 and 166: Blue Plus [Date] [Name of patient]
Page 167: Blue Plus Special Member Benefits O
Page 171 and 172: Blue Plus OB/GYN Open Access Diagno
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Page 175 and 176: BlueCard® Identifying BlueCard ®
Page 177 and 178: BlueCard® Identifying BlueCard ®
Page 179 and 180: BlueCard® BlueCard Service Claims
Page 181 and 182: BlueCard® Prior Authorization and
Page 183 and 184: BlueCard® Electronic Data Intercha
Page 185 and 186: BlueCard® Claims Processed by the
Page 187 and 188: BlueCard® Overview (continued) 3.
Page 189 and 190: BlueCard® Claim Payment Guidelines
Page 191 and 192: BlueCard® Calls from Members and O
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Page 195 and 196: BlueCard® Types of Medicare Advant
Page 197 and 198: BlueCard® Medicare Advantage Claim
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Page 201 and 202: Claims Filing HCPCS/ Accommodation
Page 203 and 204: Claims Filing Administrative Simpli
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Page 211 and 212: Claims Filing 1500 HICF Form Profes
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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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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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Prior Authorization Requirements Co
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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 (Lab
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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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