Name of Manual - Blue Cross and Blue Shield of Minnesota

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Requirements of Minnesota Law (continued) Blue Cross' Responsibilities Written Notification and Provider Liability Provider Agreements • Effective August 1, 2010, Minnesota Statute [62Q.751] states: • Providers may collect deductibles and coinsurance from patients at or prior to the time of service. • Providers may not withhold a service to a health plan company enrollee based on a patient's failure to pay a deductible or coinsurance at or prior to the time of service. • Overpayments by patients to providers must be returned to the patient by the provider by check or electronic payment within 30 days of the date in which the claim adjudication is received by the provider. Blue Cross’ responsibilities include the following: • Make payment directly to the provider for covered services, respond to inquiries and resolve claims in a timely manner • Maintaining confidentiality of the provider’s charge data in accordance with the contract terms • Establishing a peer-review process to make decisions about medical necessity • Keeping members informed of participating providers through publication of directories • Keeping providers informed of changes which are contractually binding through Provider Bulletins or other communications (i.e. Provider Manual) If it is necessary to recommend that a patient see a nonparticipating provider, the participating physician must give the patient advance, written notification that the recommendation is to a nonparticipating physician. Once notice is given, the patient is responsible for any increased liability if he or she decides to schedule the service. If a patient is not properly informed, the provider making the recommendation to a nonparticipating provider will be liable for increased costs that a patient incurs. Please refer to Waivers in Chapter 4. Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10) 2-5
Provider Agreements Provider Numbers Overview Blue Cross works with many different types of providers through contractual agreements. Agreements are in place with facilities and physician clinics to establish networks of participating providers for our members. National Provider Number (NPI) The Health Insurance Portability and Accountability Act- Administrative Simplification (HIPAA-AS) is the result of legislation passed by the U.S. Congress. The legislation mandates standards for business to business electronic data interchange and code sets, establishes uniform heath care identifiers and seeks protection for the privacy and security of patient data. The purpose of implementing the NPI is to improve the efficiency and effectiveness of the health care system by reducing the number of identifiers associated with any specific provider or provider facility. Implementation will simplify provider identification and billing processes across multiple third party payers (including government programs) and prevent fraud and abuse. The NPI is a unique all numeric 10 digit number that is assigned by the Centers for Medicare & Medicaid Services (CMS). NPI eligible providers are to submit transactions with the NPI at the facility level as well as the practitioner level. Providers who are considered Atypical (not eligible for an NPI) are to submit transactions using their DHS assigned Unique Minnesota Provider Identifier (UMPI) or the Blue Cross proprietary identification number. To register online or to find the NPI paper application form, access the CMS website at http://nppes.cms.hhs.gov. It is your responsibility to report your NPI to payers. To access the NPI submission instructions, go to bluecrossmn.com for health care providers, HIPAA/NPI Compliance. 2-6 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (01/05/10)
Page 1 and 2: Blue Cross and Blue Shield of Minne
Page 3 and 4: Recent Chapter changes: Chapter 11
Page 5 and 6: Chapter 11 - Coding Policies and Gu
Page 7 and 8: Durable Medical Equipment Date Topi
Page 9 and 10: Medical Emergency Date Topic Change
Page 11 and 12: Rehabilitative Services Date Topic
Page 13 and 14: Table of Contents Chapter 1 At Your
Page 15 and 16: Introduction Provider Policy and Pr
Page 17 and 18: How to Contact Us At Your Service P
Page 19 and 20: At Your Service Claims Address Subm
Page 21 and 22: Care Management Numbers and Address
Page 23 and 24: Care Management Numbers and Address
Page 25 and 26: Company Phone Number Address Public
Page 27 and 28: At Your Service Provider Identifica
Page 29 and 30: ID Cards At Your Service Introducti
Page 31 and 32: Electronic Commerce Overview An imp
Page 33 and 34: Remote Access Services (continued)
Page 35 and 36: Provider Communications Provider Co
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Integrated Health Management Defini
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Integrated Health Management Overvi
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Integrated Health Management Medica
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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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Health Care Options Blue Cross and
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Health Care Options Double Gold Dou
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Health Care Options Medicare Basic
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Health Care Options MedicareBlue PP
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Health Care Options Inquiries and C
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Health Care Options Additional info
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Health Care Options Minnesota Senio
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Health Care Options BlueLinkTPA Blu
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Health Care Options Prime Therapeut
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Health Care Options Workers' Compen
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Health Care Options HICF 1500 Form
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Health Care Options Networks Blue C
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Blue Plus Member Information Introd
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Blue Plus Member Rights and Respons
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Blue Plus Member Rights and Respons
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Blue Plus Member Benefits Members
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Blue Plus Quality of Care Complaint
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Blue Plus Referral Points Remember
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Blue Plus Standing Referral Minneso
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Blue Plus Clarifications of Terms (
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Blue Plus [Date] [Name of patient]
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Blue Plus Special Member Benefits O
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Blue Plus OB/GYN Open Access Diagno
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Blue Plus OB/GYN Open Access Diagno
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BlueCard® Claim Status Inquiry ...
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BlueCard® Identifying BlueCard ®
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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 Present on Admission
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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 Employment As defined
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Claims Filing Surgical Technicians
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Reimbursement / Reconciliation Reim
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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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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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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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Drugs Coding Policies and Guideline
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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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Assistant Surgeons (continued) Assi
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