Provider Manual 2017
Blue Cross and Blue Shield of Vermont
and The Vermont Health Plan
Table of Contents
Provider Manual 2017
Blue Cross and Blue Shield of Vermont
and The Vermont Health Plan
Member Identification Cards
22
Member Proof of Insurance
25
Section 4
i
Medical Utilization Management
(Care Management)
Section 1
27
Getting in Touch with BCBSVT and TVHP
1
Section 5
Plan Definitions
2
Quality Improvement (QI) Program
34
Office Training and Orientation
3
BCBSVT/TVHP Special Health Programs
35
Provider Participation and Contracting
3
Provider Selection Standards
36
Access Standards
10
Section 6
Availability of Network Practitioners 11
Opening/Closing of Primary Care Provider Patient Panels
PCP Initiated Member Transfer
12
Transitioning Pediatric Patients
12
Notification of Change In Provider and/or Group Information
11
12
Utilization Management Denial Notices: Reviewer Availability 14
Complaint and Grievance Process
14
General Claim Information
39
When to Collect a Co‑payment
41
Member Confidential Communications:
45
Claim Specific Guidelines
45
Claim Submission and Reimbursement Guidelines 46
Section 7
Health Insurance Portability and Accountability Act (HIPAA)
Responsibilities15
The BlueCard™ Program Makes Filing Claims Easy 58
How Does the BlueCard Program Work?
58
Member Rights and Responsibilities
Claim Filing
61
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan
Privacy Practices16
Frequently Asked Questions
64
Glossary of BlueCard Program Terms
66
Section 2
BlueCard Program Quick Tips
67
Blue Cross and Blue Shield of Vermont Web Site
16
17
Section 3
Section 8
Blue Cross and Blue Shield of Vermont and the Blueprint
Program:68
Member Accumulators
21
Member Eligibility
21
Section 9
Member Confidential Communications:
22
The Federal Employee Program (FEP):
Standard Confidential Communication:
22
Confidential Communication for Sexual Assault:
22
Index
72
Section 1
Getting in Touch with BCBSVT and TVHP
A customer service team specializing in provider issues staffs the following lines. The lines are open weekdays
from 7 a.m. until 6 p.m. Please have the following information available when you call:
•Your National Provider Identifier(s).
•Your patient’s identification number, including the alpha prefix and suffix if applicable.
BCBSVT & TVHP Telephone Directory http://www.bcbsvt.com/provider/contact-info
Contact Us:
By Mail
PO Box 186, Montpelier, VT 05601-0186
In Person
445 Industrial Lane, Montpelier, VT 05602
On The Web
Our website, www.bcbsvt.com, has a variety of services for providers and members. Section 2 of this manual has more information about it.
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic communications that
contain Protected Health Information (PHI) to be secure. To comply with this important and practical security measure,
we use services of a company called Proofpoint to protect our e-mail and ensure all PHI remains confidential.
When a BCBSVT/TVHP employee sends you an e-mail that contains PHI, Proofpoint detects the PHI and protects the e-mail. You will receive an
e-mail notification that you have been sent a Proofpoint secure message. The notification tells you who the secure message is from and includes
a link to retrieve the e-mail message. The first time you use the Proofpoint message service to retrieve a message, you must create a password.
Thereafter, you can use the same password each time you log into the Proofpoint Center to retrieve an encrypted BCBSVT/TVHP e-mail.
Please note—Proofpoint secure messages are posted and available for 30 calendar days. If the message
is not opened during that timeframe, the message is removed and the sender notified.
If you would like more information about Proofpoint, visit the following website: https://securemail.bcbsvt.com/help/enus_encryption.html
1
Plan Definitions
Accountable Blue
SM
The Accountable Blue product is modeled after our Vermont Health
Partnership® products. Members, however, have a reduced liability
when they receive care from providers who are part of the Accountable
Blue Team, mindful that there is no standard level of benefits
available to members. The Accountable Blue Team consists of Central
Vermont Medical Center and other Central Vermont providers. Please
refer to Vermont Health Partnership definition for full details.
CBA Blue®
CBA Blue is a third-party administrator (TPA) owned by
BCBSVT. Providers contract for CBA through BCBSVT.
CBA Blue members have unique prefixes. A complete listing
of prefixes for CBA Blue members is available on our provider
website at www.bcbsvt.com under references/prefixes.
Claims for CBA Blue members need to be submitted to CBA Blue directly.
Please contact CBA Blue directly with any customer
service or claim processing related questions.
Their contact information is available on our Contact Information For Provider
listing on our provider website at www.bcbsvt.com under contact us.
program. The plan encourages patient responsibility and involvement in
health care by encouraging members to choose participating providers.
Patients may seek services from non-participating providers, but in most
cases they will pay higher deductible and/or coinsurance amounts.
The Vermont Freedom Plan provides coverage with no deductible for
office visits, well-baby care, and physicals. This plan requires members
to pay a deductible and/or co-payment. The provider network for the
Vermont Freedom Plan is our preferred provider network (PPO).
All plans have a prior approval requirement for select medical
procedures, durable medical equipment and select prescription drugs.
Vermont Blue 65 Medicare Supplemental
Insurance (formerly Medi-Comp)
SM
Vermont Blue 65 (formerly Medi-Comp): is a supplement available
to individuals who have Medicare Parts A and B coverage. Effective
1/1/2005, BCBSVT changed the name of its Medicare Supplemental plans
from Medi-Comp I, II, III, A and C to Vermont Blue 65 Plans I, II, III, A and
C. It helps pay co-payments and coinsurance for Medicare-approved
services. In some cases, the individuals will have to pay for all or part of
the health care services. Benefits are provided only for approved Medicareeligible services provided on or after the effective date of coverage.
BlueCard®
See BlueCard Section 7 for details
Federal Employee Program (FEP)
New England Health Plan (NEHP)
The Federal Employee Program (FEP) is a health care plan
for government employees, retirees, and their dependents. It
provides hospital, professional provider, mental health, substance
abuse, dental and major medical coverage of medically necessary
services and supplies. BCBSVT processes claims for FEP services
rendered by Vermont providers to FEP members. Members with
FEP coverage have ID numbers that begin with alpha prefix R.
See BlueCard, Section 7, for details.
Indemnity (Fee-for-Service) and Preferred
Provider Organization (PPO)
TVHP plans encourage members to stay healthy by providing
preventive care coverage at no cost to the member. Members
must get prior approval for certain medical procedures, durable
medical equipment and certain prescription drugs. They must
also get prior approval for out-of-network services.
Comprehensive: Comprehensive coverage has an annual deductible
amount and coinsurance up to an annual “out-of-pocket” limit. It
provides benefits for medical and surgical services performed by
licensed physicians and other eligible providers, necessary services
provided by inpatient/outpatient facilities and home health agencies,
ambulance services, durable medical equipment, medical supplies,
mental health/substance abuse services, prescription drugs,
physical therapy and private duty nursing. The provider network for
Comprehensive coverage is the participating provider network.
Vermont Freedom Plan® (VFP): the Vermont Freedom Plan combines
the features of our Comprehensive coverage with a managed benefit
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The Vermont Health Plan (TVHP)
The Vermont Health Plan (TVHP) is a BCBSVT affiliate that is a Vermontbased managed care organization offering a cost-effective, high-quality
portfolio of managed care products. The Vermont Health Plan offers an
HMO product, BlueCare, and a point-of-service plan, BlueCare Options.
Members must use network providers for mental health and
substance abuse care. These services also require prior approval.
BlueCare Access: Members use the BlueCard Preferred Provider
Organization (PPO) network when receiving services outside of the
State of Vermont and still receive the preferred level of benefits.
Blue Care®: A PCP within The Vermont Health Plan’s network
coordinates a member’s health care. Members must get prior
approval for certain services and prescription drugs. No outof-network benefits are available without prior approval.
Blue Care Options: A network PCP coordinates a member’s health
care, but members have the option of seeking care out of network at a
lower benefit level (standard benefits). Standard benefits apply when
members fail to get the Plan’s approval to use non-network providers,
(subject to the terms and conditions of the subscriber’s contract).
Members pay higher deductibles and coinsurance with standard benefits.
If members receive care within the network or get appropriate prior
approval, they receive a higher level of benefits (preferred benefits).
Members with TVHP benefits can be identified by alpha prefix ZIE.
Vermont Health Partnership (VHP)
Members covered under Vermont Health Partnership select a network
PCP. Members pay a co‑payment for services provided by their PCP's
(except defined preventive care)as well as specialty office visits. VHP
covers hospital care, emergency care, home health care, mental health
and substance abuse treatment. Co-payments or deductibles may apply.
Members must get prior approval for out-of-network care, certain medical
procedures, durable medical equipment and certain prescription drugs.
VHP offers two levels of benefits, preferred and standard. Members
get preferred benefits when using VHP network providers, or
when they get our prior approval to use out-of-network providers.
Standard benefits are available for some out-of-network services,
meaning higher out-of-pocket expenses for the member.
Members must use network mental health and substance
abuse care providers and must get prior approval.
Members with VHP benefits can be identified by the alpha prefix ZIH.
University of Vermont Open Access Plan
SM
University of Vermont Open Access Plan: This open access plan
is based on our Vermont Health Partnership product. It differs in
that it allows members to utilize the BlueCard Preferred Provider
Organization (PPO) network when receiving services outside of the
State of Vermont and still receive a preferred level of benefits. Please
refer to Vermont Health Partnership definition for full details.
Riders
Riders amend subscriber contracts. They usually add coverage
for services not included in the core benefits. Employer groups
may purchase one or more riders. Examples include:
•Prescription Drugs
•Vision Examination
•Vision Materials
•Fourth Quarter carry over of deductible
•Benefit Exclusion Rider
•Infertility Treatment
•Sterilization
•Non-covered Surgery
•Dental Care
Office Training and Orientation
Your BCBSVT provider relations consultant can assist you in several ways.
•Provider contracting information and interpretation
•On-site visits
•Provider and office staff education and training
•Information regarding BCBSVT policies, procedures, programs and services
•Information regarding electronic claims options
Provider Participation and Contracting
Providers contract with BCBSVT and/or TVHP either directly or through
PHOs. If you contract with BCBSVT and/or TVHP through a PHO or
physician/hospital group, you may obtain a copy of your contract with
us from the PHO administrative offices with which you are affiliated.
If you contract directly with BCBSV T/TVHP, you are given a copy of
the contract signed by all parties at the time of its execution.
Contracting
Provider contracts define the obligations of all parties. Responsibilities
include, but are not limited to: obligations relating to licensure,
professional liability insurance, the delivery of medically necessary health
care services, levels of care, rights to appeal, maintenance of written
health records, compensation, confidentiality, the term of the contract,
the procedure for renewal and termination and other contract issues.
All parties affiliated are responsible for the terms and conditions set
forth in that contract. Refer to your contract(s) to verify the BCBSVT and/
or TVHP products with which you participate. You may have separate
contracts or amendments for participation in different BCBSVT and/or
TVHP products such as Indemnity (fee-for-service), Federal Employee
Program, Vermont Health Partnership or The Vermont Health Plan.
3
Participation
The following provider contracts are available:
Indemnity (fee-for-service)/Vermont Health Partnership
A combined contract that includes participation in:
•Accountable Blue
•BlueCard (out-of-area) Program
•CBA Blue
•Federal Employee Program (excluding dental services)
•Medicare Supplemental Insurance (Vermont Blue 65, formerly ­Medi‑comp)
•Preferred Provider Organization (PPO) (Vermont Freedom Plan)
•Traditional Indemnity (Fee-for-Service) Plans (J Plan,
Comprehensive and Vermont Freedom Plan)
•University of Vermont Open Access
•Vermont Health Partnership
•Any other program bearing the BCBS service marks
The Vermont Health Plan Contract
•Contracts may be direct or through a contracted PHO
Providers who are under contract with BCBSVT for TVHP, are "participating
providers" or "in-network providers." These providers submit claims
directly to us, and receive claim payments from us. Participating and
network providers accept the Plan's allowed price as payment in full
for covered services, and agree not to balance bill Plan members.
TVHP members pay any co-payments, deductibles and coinsurance
amounts up to the allowed price, as well as any non-covered services.
Incentives for Participation
Participation with the Plan offers the following advantages:
•Direct payment for all covered services offers predictable cash flow,
and minimizes collection activities and bad debt exposure.
•Claims you submit are processed in a timely manner. We make available
either electronic (PDF or 835 formats) or paper remittance advices which
detail our payments, patient responsibilities, adjustments and/or denials.
•Electronic Fund Transfers (EFT)/direct deposit for payments. Please
note: if you select EFT/direct deposit you will no longer receive a paper
remittance advice. A PDF format remittance advice is available on
line to print or download or the 835 transaction is also available.
•Members receiving services are provided with an Explanation
of Benefits (EOB) statement identifying payments, deductible,
coinsurance and co-payment obligations, adjustments and denials.
The member’s EOB explains the provider’s commitment to
patients through participation with BCBSVT and/or TVHP.
•The Plan has dedicated professionals to assist and educate
providers and their staff with the claims submission process,
4
policy directives, verification of the patient’s coverage and
clarification of the subscriber’s and provider’s contract.
•Online and paper provider directories contain the name, gender,
specialty, hospital and/or medical group affiliations, board
certification, if the provider is accepting new patients, languages
spoken by the provider and office locations of every eligible provider.
These directories are available at no charge to current and potential
members and employer groups. This information is also available
to provider offices for references or referrals on our website at
www.bcbsvt.com. For more information on provider directories,
refer to Providers Listing in Member Directories later in this section.
•Providers and their staff are given information on policies, procedures,
and programs through informational mailings, newsletters,
workshops and on-site visits by provider relations consultants.
•The Plan accepts electronically submitted claims in a HIPAA
compliant format and provides advisory services for system eligibility.
Automatic posting data is available to electronic submitters.
•Participating providers have around-the-clock access to the BCBSVT
website at www.bcbsvt.com, which provides claims status information,
member eligibility, medical policies and copies of informative mailings.
Definition of Network Provider
BCBSVT/TVHP defines Primary Care Provider and
Specialty Care Provider by the following:
Primary Care Provider (PCP):
The BCBSVT Quality Improvement Policy, PCP Selection Criteria
Policy provides the complete details of the selection criteria. The
policy is located on the secure provider portal at www.bcbsvt.com
under BCBSVT Policies then the Quality Improvement link. Or, you
can call your provider relations consultant for a paper copy.
A network provider whom members in managed care health
plans may select to manage their care. Providers are eligible
to be PCPs if they have a specialty in family practice, internal
medicine, general practice, pediatrics, geriatrics or naturopath.
Certain Advance Practice Registered Nurses (APRN) can carry a patient
panel.* Specifically, the APRN must practice in a state that permits APRNs
to carry a patient panel and otherwise meet BCBSVT requirements for
primary care providers requirement for PCP and defined by the BCBSVT
Quality Improvement Policy, PCP Selection Criteria Policy. In addition, the
APRN must have completed transition to practice requirements and must
hold certification as an adult nurse provider, family nurse practitioner,
gerontological nurse practitioner or pediatric nurse practitioner.
*APRN's cannot be primary care providers for
New England Health Plan Members.
Specialty Care Provider (SPC): A network provider
who is not considered a primary care provider.
Enrollment of Providers
To enroll, the group or individual must hold a contract with
BCBSVT and/or TVHP, or a designated entity and the individual
providers to be associated must be enrolled and credentialed.
Enrollment—The forms for enrolling are located on our provider website
at www.bcbsvt.com under forms, enrollment and credentialing.
There are two forms; Provider Enrollment Change Form (PECF) and
Group Provider Enrollment Change Form (GPECF) Form(s) must be
completed in their entirety and include applicable attachments as
defined on the second page of each form. ). If you are a mental health
or substance abuse clinician in addition to the forms mentioned
above, you also need to complete and Area of Expertise Form.
The PECF must be used for adding a new physician/provider to a practice
(new or existing practice), opening or closing of patient panel, changing
physician/providers practicing location, termination* of a physician/
provider from group and changing of a physician/providers name.
*Please note: We will accept an email for termination
of a provider, rather than the PECF. Please see details
below in "Deleting/Terminating a Provider" section.
The GPECF must be used for enrolling a new group practice including
independent providers in private practice setting, or updating an existing
group information such as; tax identification number, group billing
national provider identifier (NPI), billing, physical or correspondence
addresses and/or group name. Note: new groups/practices need
to complete the GPECF and a PECF for each physician/provider
that is going to be associated with that group/practice.
Mental Health and Substance Abuse clinicians must complete an
Area of Expertise form in addition to the forms listed above
Independent physicians/providers need to complete both
the PECF and GPECF for enrollment or changes.
Blueprint Patient Centered Medical Homes (existing and new) need to
inform BCBSVT of provider changes (defined above) by using the PECF or of
group practice changes (defined above) by using the GPECF. The Blueprint
Payment Roster Template is not our source of record for these changes..
PLEASE NOTE: BCBSVT is able to accept enrollment paperwork and
begin the enrollment and credentialing process even if a provider is
pending issuance of a State of Vermont Practitioner’s license. If this
is the case, simply indicate on the Provider Enrollment Change Form
“pending” for license# in Section 3, Provider Information. Upon
your receipt of the license, immediately forward a copy by fax or
e-mail at: fax (802) 371‑3489 or e-mail [email protected]
or if you prefer the copy can be mailed to the attention of Network
Management at BCBSVT, PO Box 186, Montpelier, VT 05601-0186.
Upon receipt of the Vermont State licensure, BCBSVT will continue
the enrollment process. Please be aware the enrollment process
can not be fully completed until all paperwork is received.
Enrollment of Locum Tenen—You must complete a Provider
Enrollment/Change form and indicate in Section 3, Locum Tenen
who the provider is covering for and how long they will be covering.
Locum Tenen’s who will be covering for another provider for a period
of 6 months or less do not require credentialing. If the coverage is
expected to exceed 6 months, then credentialing paperwork must
be filed. Locum Tenens are not marketed in directories and if in a
primary care practice setting, cannot hold a direct patient panel.
Provider Credentialing—The first step is to complete or
update a Council for Affordable Quality Healthcare (CAQH)
application. We are providing high level details below,
however for complete detailed instructions, please refer to the
Provider Quick Reference Guide on the CAQH website.
Providers should use https://proview.caqh.org/pr
to access their CAQH application.
Practice managers should use https://proview.caqh.org/pm
to access the provider's CAQH application.
If you encounter any issue using the CAQH website
or have questions on the process, please contact the
CAQH Provider Help Desk at (888) 599-1771.
1. Providers Currently Affiliated with CAQH
•Log onto https://proview.caqh.org/pr using your CAQH ID number
•Re-attest the information submitted is true and accurate to the best
of your knowledge. Please note that malpractice insurance information
must be up-to-date and attached electronically. Also, practice locations
need to be updated to indicate the group that the provider is being
enrolled in.
•If you do not have a “global authorization”, you will need to assign
BCBSVT as an authorized agent, allowing BCBSVT access to your
credentialing information.
2. Providers Not Yet Affiliated with CAQH
•CAQH has a self-registration process. Go to
https://proview.caqh.org/pr, if you are the provider or if you are a
practice manager, use https://proview.caqh.org/pm to complete an
initital registration form. The form will require the provider/practice
5
to enter identifying information, including an email address and NPI
number.
•Once the initial registration form is completed and submitted, the
provider/practice manager will immediately receive an email with a
new CAQH provider ID.
•Login to CAQH with the ID and create a unique username and
password.
•Complete the online credentialing application; be sure to include copies
of current medical license, malpractice insurance and if applicable Drug
Enforcement Agency License.
•If you do not have a "global authorization", you will need to assign
BCBSVT as an authorized agent, allowing BCBSVT access to your
credentialing information.
•If a participating organization you wish to authorize does not
appear, please contact that organization and ask to be added to
their provider roster.
Providers Without Internet Access
•Providers without Internet access must contact CAQH’s Universal
Credentialing DataSource Help Desk at (888) 599-1771 and request a
CAQH application be mailed to you.
•You must complete the application and return to CAQH for entry at:
•ACS Health Care Solutions
Attn: (CAQH) 4550 Victory Lane
Indianapolis, IN 46203 or FAX (866) 293-0414
•Please include copies of current medical license, malpractice insurance
coverage and DEA certificate (if applicable).
•Assign BCBSVT as an authorized agent, allowing BCBSVT access to your
credentialing information.
Once authorization has been given and your application is complete,
CAQH will provide notification and Med Advantage* will begin to process
your application and primary source verify your credentialing information.
If for some reason your primary source verification exceeds
60 days, you will be notified in writing of the status and every
30 days thereafter, until the credentialing process is complete.
Upon completion of credentialing, you or your group practice
will receive a confirmation of your assigned NPI, networks
in which you’re enrolled and your effective date.
Med Advantage
If you apply for credentialing through the BCBSVT/TVHP joint credentialing
committee, primary source verification will be completed by our agent, the
National Credentialing Verification Organization (NCVO) of Med Advantage.
Provider Listing in Member Directories
6
All providers are marketed in the on line and paper
provider directories, except those noted below:
•Providers who practice exclusively within the facility or free standing
settings and who provide care for BCBSVT members only as a
result of members being directed to a hospital or a facility.
•Dentist who provide primary dental care only under a dental plan or rider
•Covering providers (e.g., locum tenens)
•Providers who do not provide care for members in a
treatment setting (e.g., board-certified consultants)
The following provider information is supplied in the directories:
•Name, including both first and last name of the physician or provider
•Gender
•Specialty, determined based on education, training and when
applicable, certifications held during the credentialing process.
Providers may request to be listed in multiple specialties if
their education and training demonstrates competence in each
area of practice. Approved lists of specialties and certificate
categories from one of the below entities is accepted:
•American Board of Medical Specialties: www.abms.org
•American College of Nurse Midwives-Certification Council:
www.addmidwife.org
•American Nurses Association: www.ana.org
•American Osteopathic Association: www.osteopathic.org
•The Royal College of Pathologists: www.rcpath.org
•The Royal College of Physicians: www.rcplondon.ac.uk
•The College of Family Physicians of Canada: www.cfpc.ca
•Hospital affiliations, admitting/attending privileges at listed hospitals
•Board certification, including a list of board certification
categories as reported by the ABMS.
•Medical Group Affiliations, including a list of all medical
groups with which the physician is affiliated.
•Acceptance of new patients
•Languages spoken by the physician
•Office location, including physical address and
phone number of office locations
Credentialing Policy:
The BCBSVT Quality Improvement Credentialing Policy includes details
of the credentialing process for hospital based providers, credentialing
and re-credentialing criteria, verification process, quality review and
credentialing committee review, acceptance to the network, ongoing
monitoring, confidentiality and practitioner rights in the credentialing
process. The policy is located on the secure provider portal at www.
bcbsvt.com under BCBSVT Policies the Quality Improvement link. Or,
you can call your proivder relations consultant for a paper copy.
of the grace period, months two and three will be recovered. For full details
on Grace Periods, see "grace period for individuals through the Exchange".
Your rights during the credentialing process:
•To receive information about the status of the credentialing application
on request. Upon request for information, the credentialing coordinator
will inform you of the status of your credentialing application and the
anticipated committee review date.
•To review information submitted to support the credentialing/
re-credentialing application. You may request to review the
information submitted in support of the credentialing application.
Upon request, you will have the opportunity to review non-peer
protected information in the credentialing file during an agreed upon
appointment time. The appointment time will be during regular
business hours in the presence of the credentialing coordinator.
•To correct erroneous/inaccurate information. The Plan will notify
you in wriring if information on the application is inconsistent with
information obtained via primary source verification. You have the
right to correct erroneous information received from verification
sources direcxtly with the verifying source. You must respond to the
Plan in writing to address any conflicting information provided on the
application. We will review your response to ensure resolution of the
discrepancy. We evaluate all applications against Plan criteria and may
require a credentialing committee review if your application does not
meet Plan criteria.
Paper Check: Providers, upon effective date of contract,
are automatically set up to receive weekly paper remittance
advice and check that are mailed using the US postal system.
Facility Credentialing
Open Communication
The BCBSVT Quality Improvement Policy, Facility Credentialing provides
the complete details. The policy is located on the secure provider portal at
www.bcbsvt.com under BCBSVT Policies then the Quality Improvement
link. Or, you can call your provider consultant for a paper copy.
BCBSVT and TVHP encourage open communication between
providers and members regarding appropriate treatment
alternatives. We do not penalize providers for discussing
medically necessary or appropriate care with members.
Reimbursement
Conscientious Objections to the Provision of Services
We reimburse providers in one of two ways, using one of two methods:
Providers are expected to discuss with members any conscientious
objections he or she has to providing services, counseling or referrals.
Fee for Service: reimbursement for a service rendered, an amount paid to
a provider based on the Plan’s allowed price for the procedure code billed.
Capitation: a set amount of money paid to a Primary Care Provider
or PHO. The amount is expressed in units of per member per month
(PMPM). It varies according to factors such as age and sex of the enrolled
members.Primary Care Providers (PCPs) in private or group practices
who are under a capitated arrangement will receive a monthly
capitated detail report. The report is mailed before the 20th business
day of every month. Each product is issued a separate capitation
detail report and check. The report lists the members assigned to the
PCP and the capitation amount the provider is being paid PMPM.
Capitation is paid during the three month grace period for individuals covered
through the Exchange (prefix ZII). If the member is terminated at the end
Electronic Fund Transfer (EFT)/direct deposit: Providers can
opt to receive electronic fund transfers (EFT)/direct deposit. Sign
up for EFT/direct deposit is electronic and on the BCBSVT.com
provider website. BCBSVT partners with Change Healthcare*
to offer this service. It is free and you do not have to submit claims
or have a relationship with Change Healthcare* to receive the
service. Simply click on the link, complete the form and Change
Healthcare* will be in contact with you to complete the process.
When you sign up to receive EFT/direct depsoit you also commit to pick up
your remits in an electronic format (either PDF or 835). The PDF versions
of the remits are available on the Change Healthcare* or BCBSVT
websites. Thirty days after your first EFT/direct deposit payment, our paper
remits will stop being mailed. Electronic remits remain available on the
secure website for a 6 year period.
(* formerly Emdeon).
Provider Roles and Responsibilities
Follow-up and Self-care
Providers must assure that members are informed of specific health care
needs requiring follow-up and that members receive training in self‑care
and other measures they may take to promote their own health.
Coordination of Care
VHP and TVHP members select Primary Care Providers (PCPs)
responsible for coordinating care. Providers are responsible for requesting
information necessary to provide care from other treating providers.
When a member is referred to a specialist or other provider, we require
the specialist or provider to send a medical report for that visit to the
PCP to ensure that the PCP is informed of the member’s status.
7
We have created and posted a template that can be used to facilitate the
communication between behavioral health and primary care providers
to assist in patient care coordination for patients receiving mental health
or substance abuse services. This template is available on our provider
website link under provider manual & reference guide, general information,
communication form for behavioral health and primary care providers.
Primary Care Provider Coordinates Care
Except for self-referred benefits, in a managed care plan all covered
health services should be delivered by the PCP or arranged by the PCP.
The PCP is responsible for communicating to the specialist information
that will assist the specialist in consultation, determining the diagnosis,
and recommending ongoing treatment for the patient. While none
of our Plans (except the New England Health Plan) require referrals,
we encourage members to coordinate all care through their PCPs.
Specialty Provider Responsibilities
Specialty providers are responsible for:
•Communicating findings surrounding a patient to the patient’s
PCP to ensure that the PCP is informed of the member’s status
•Obtaining prior approval as appropriate.
Continuity of Care
BCBSVT and TVHP support continuity of care. We allow standing referrals
to specialists for members with life threatening, degenerative or disabling
conditions. A specialist may act as a PCP for these members if the specialist
is willing to contract as such with the Plan, accept the Plan’s payment rates
and adhere to the Plan’s credentialing and performance requirements.
A request for a specialist to act as his or her PCP must come from the
patient, and our medical director must review and approve the request.
Providers may contact the customer service unit to
initiate a request for a standing referral.
A pregnant woman in her second or third trimester enrolling
in a managed care plan can continue to obtain care from her
current provider if he or she is out-of-network until completion of
postpartum care if the provider agrees to specific conditions.
A new member with life threatening, disabling or degenerative
conditions with an ongoing course of treatment with an out-of-network
provider may see this provider for 60 days after enrollment or until
accepted by a new provider. Disabling or degenerative conditions
are defined as chronic illnesses or conditions (lasting more than one
year), which substantially diminish the person’s functional abilities.
Our medical director must review and approve the request.
8
Confidentiality and Accuracy of Member Records
Providers are required to:
•Maintain confidentiality of member-specific information from
medical records and information received from other providers.
This information may not be disclosed to third parties without written
consent of the member. Information that identifies a particular
member may be released only to authorized individuals and in
accordance with federal or state laws, court orders or subpoenas.
Unauthorized individuals must not have access to or alter patient records.
•Maintain the records and information in an accurate and timely
manner, ensuring that members have timely access to their records.
•Abide by all federal and state laws regarding confidentiality
and disclosure for mental health records, medical records,
and other health and member information.
•Records must contain sufficient documentation that services
were performed as billed on submitted claims.
•Providers are responsible for correct and accurate billing including
proper use as defined in the current manuals: AMA Current
Procedural Terminology (CPT) Health Care Procedure Coding
System (HCPCS), and most recent International Classification
of Diseases Clinical Modification (currently, ICD 9 CM).
Access to Facilities and Maintenance of Records for Audits
BCBSVT and TVHP (as the managed care organization), their providers,
contractors and subcontractors and related entities must provide state
and federal regulators full access to records relating to BCBSVT and
TVHP members, and any additional relevant information that may be
required for auditing purposes. Medical Record Audits may include the
review of financial records, contracts, medical records, and patient care
documentation to assess quality of care, credentialing and utilization.
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT
reviewing and responding to "Advanced Benefit Determinations".
This allows members and providers to submit a request in
writing asking for benefit availability for specific services and
receive a written response on coverage. Refer to section 4 Advanced Benefit Determination for further information.
Prior Approval/Referral Authorization
Participating and network providers are financially responsible
for securing prior approvals and referral authorizations before
services are rendered; even if a BCBSVT/TVHP policy is secondary to
Medicare. For more information on services requiring Prior Approval
or referral authorizations, please refer to Section 4.
Billing of Members
Covered Services: Participating and network providers accept the fees
specified in their contracts with BCBSVT and TVHP as payment in full
for covered services. Providers will not bill members for amounts other
than applicable co-payments, coinsurance or deductibles. We encourage
providers to use their remittance advices as the source of member
liability for collection of deductibles and coinsurance and bill members.
Copayments, deductibles and coinsurance, however, can be billed to the
member at the point of service, prior to rendering of service(s). In order
to bill for these liabilities, providers must call our Customer Service
Department to ensure the correct collection amount. If after receipt of the
remittance advice the member liabilities are reduced, the provider must
provide a quick turn-around in refunding the member any amounts due.
Non-Covered Services
Non-Covered Services: In certain circumstances, a provider may bill
the member for non-covered services. In these cases, the collection
should occur after you receive the remittance advice which reports the
service as non-covered and shows the amount due from the member.
We require that you explain the cost of a non-covered service to the
member and get the member’s signature on an acknowledgement
form, before you provide non-covered services.
To verify if a service is covered, you may contact
the appropriate customer service center.
Missed Appointments: The provider must post or have available
to patients the office policy on missed appointments. If a member
does not comply with the requirement and there is a financial penalty,
the member may be billed directly for that service. A claim should
not be submitted to BCBSVT. Supporting documentation related to
the incident needs to be noted in the members medical records.
Services where Medicare is primary, but provider (1) does not
participate/accept assignment and (2) is contracted with BCBSVT:
Providers must adhere to the guidelines described in this section on
"covered services" and/or "non-covered services". Providers will
submit the claims directly to Medicare on behalf of the member. As
BCBSVT participates in the Coordination of Benefits Agreement
(COBA) Program with the Centers for Medicare and Medicaid Services
(CMS), the claim will cross over directly for processing through the
BCBSVT system. A remittance advice and any eligible payments
will be made directly to the provider. Providers may collect from the
member any payments Medicare made directly to the member as
well as any member liabilities not collected at the point of service.
The FEP program does not participate in the COBA program. The provider
should make best efforts to obtain a copy of the Explanation of Medicare
Benefits (EOMB) from the member for submission to BCBSVT or assist
the member with the submission of the claim and EOMB to BCBSVT.
See Section 6, "Providers who do not accept Medicare
Assignment and are contracted with BCBSVT" for the
details of how we price and process the claim.
Services where Medicare is primary, but provider
(1) does not participate/accept assignment,
and (2) is contracted with BCBSVT:
Providers must adhere to the guidelines described in this section on
"covered services" and/or "non-covered services". Providers will submit
the claims directly to Medicare on behalf of the member. As BCBSVT
participates in the Coordination of Benefits Agreement (COBA) Program
with the Centers for Medicare and Medicaid Services (CMS), the claim
will cross over directly for processing through the BCBSVT system. A
remittance advice and any eligible payments will be made directly to
the provider. Providers may collect from the member any payments
Medicare made directly to the provider. Providers may collect from
the member any payments Medicare made directly to the member as
well as any member liabilities not collected at the point of service.
The FEP program does not participate in the COBA program. The provider
should make best efforts to obtain a copy of the Explanation of Medicare
Benefits (EOMB) from the member for submission to BCBSVT or assist
the member with the submission of the claim and EOMB to BCBSVT.
See Section 6 "Providers who do not accept Medicare
assignment and are contracted with BCBSVT" for the
details of how we price and process the claim.
Waivers
Services or items provided by a contracted/network provider that are
considered by BCBSVT to be Investigational, Experimental or not Medically
Necessary (as those terms are defined in the member's certificate of
coverage) may be billed to the patient if the following steps occur:
1. The provider has a reasonable belief that the service or item is
Investigational, Experimental or not Medically Necessary because:
(a) BCBSVT customer service or an eligibility request (using the
secure provider web portal or a HIPAA-compliant 270 transaction)
has confirmed that BCBSVT considers the service or item to be
Investigational, Experimental or not Medically Necessary; or (b)
BCBSVT has issued an adverse determination letter for a service or item
requiring Prior Approval; or (c) the provider has been routinely notified
by BCBSVT in the past that for members under similar circumstances
the services or items were considered Investigational, Experimental or
not Medically Necessary.
2. Clear communication with the patient has occurred. This can be face
9
to face or over the phone but must convey that the service will not be
reimbursed by their insurance carrier and they will be held financially
responsible. The complete cost of the service has been disclosed to the
member along with any payment requirements; and
3. A waiver accepting financial liability for those services has been
signed by the member and provider prior to the service being
rendered. The waiver needs to clearly identify all costs that will be
the responsibility of the member and once signed, placed in the
member’s medical records.
4. Unless the member chooses otherwise, a claim for the service or item
must be submitted to BCBSVT. It allows the member to have a record
of processing for his/her files, and if he/she has an HSA or some type of
healthcare spending account, file a claim.
After Hours Phone Coverage
BCBSVT/TVHP requires that primary care providers (i.e., internal
medicine, general practice, family practice, pediatricians, naturopaths,
qualifying nurse practitioners) and OBGYNs provide 24-hour, seven
day a week access to members by means of an on-call or referral
system. Integral to ensuring 24‑hour coverage is members’ ability
to contact their primary care provider and/or OBGYN after regular
business hours, including lunch or other breaks during the day. Afterhours telephone calls from members regarding urgent problems
must be returned in a reasonable time not to exceed two hours.
Accessibility of Services and Provider
Administrative Service Standards:
The BCBSVT Quality Improvement Policy, Accessibility of Services and
Provider Administrative Service Standards provides the complete details on
the definition, policy, methodology for analyzing practitioner performance
and reporting. The policy is located on the secure provider portal at
www.bcbsvt.com under BCBSVT Policies then the Quality Improvement
link. Or, you can call your provider consultant for a paper copy.
Compliance Monitoring
BCBSVT/TVHP monitors access to after-hours care through periodic audits.
The plan places calls to providers' offices to verify acceptable after-hours
practices are in place. The Plan will contact providers not in compliance
and work with those practices to develop plans of corrective action.
Reporting of Fraudulent Activity
If you suspect fraudulent activity is occurring, you need
to report it to the fraud hot line at (800) 337-8440. Calls
to the hot line are confidential. Each call to the hot line is
investigated and tracked for an accurate outcome.
10
BCBSVT Audit
The complete Audit, Sampling and Extrapolation Policy is
available on our provider website at www.bcbsvt.com.
Here is a high level overview:
For the purpose of the audit investigation, the contemporaneous records
will be the basis for the Plan's determination. If the provider modifies the
medical record later, it will not affect the audit results. Audit findings are
based on documentation available at the time of the audit. Audit findings
will not be modified by entry of additional information subsequent to
initiation of the audit, for example to support a higher level of coding.
Additional clinical information pertinent to the continuum of
care that affects the treatment of the patient and to clarify health
information may be accepted prior to the closure of the audit and
will be reviewed (e.g. patient intake form, lab/radiology reports).
The Plan reserves the right to conduct audits on any provider and/
or facility to ensure compliance with the guidelines stated in Plan
policies, provider contracts or provider manual. If an audit identifies
instances of non-compliance with this payment policy, the Plan
reserves the right to recoup all non-compliant payments.
Provider Initiated Audit
Written notification needs to be sent to assigned Provider
Relations Consultant 30 days prior to the audit being initiated.
The Provider Relations Consultant will contact the provider
group and coordinate the detail specific to completing the audit,
such as when, required information and format of document.
Access Standards
Primary Care and OBGYN Services
BCBSVT/TVHP include the specialties of general practice, family
practice, internal medicine and pediatrics in their definitions of
Primary Care Providers. BCBSVT/TVHP monitors compliance with
the standards described below. We use member complaints, dis
enrollments, appeals, member satisfaction surveys and after-hours
telephone surveys to monitor compliance. If a provider does not meet
one of the below listed standards, we will work with the provider
to develop and implement an improvement plan. The following
standards for access applies to care provided in an office setting:
•Access to medical care must be provided
24 hours a day, seven days a week.
•Appointments for routine preventive examinations,
such as health maintenance exams, must be available within
90 days with the first available provider in a group practice.
•Appointments for routine primary care (primary care for non-urgent
symptomatic conditions) must be available within two weeks.
•Appointments for urgent care must be available within 24 hours
(urgent care is defined as services for a condition that causes symptoms
of sufficient severity, including severe pain, that the absence of
medical attention within 24 hours could reasonably be expected
by a prudent layperson who possesses an average knowledge of
health and medicine, to result in: placing the member’s physical or
mental health in serious jeopardy; or serious impairment to bodily
functions; or serious dysfunction of any bodily organ or part).
•Appointments for non-urgent care needs, a member must be seen
within two weeks of a request (excluding routine preventive care).
•Emergency care must be available immediately.
•Routine laboratory and other routine care
must be available within 30 days.
If a provider does not meet one of the above standards, we work
with the provider to develop and implement a plan of correction.
The BCBSVT/TVHP administrative services standards
for PCP and OB/GYN offices are as follows:
•Wait time in the waiting room shall not exceed 15 minutes
beyond the scheduled appointment. If wait is expected to exceed
15 minutes beyond the scheduled appointment, the office notifies
the patient and offers to schedule an alternate appointment.
•Waiting to get a routine prescription renewal (paper or call
in to patient’s pharmacy) shall not exceed three days.
•Call back to patient for a non-urgent problem shall not exceed 24 hours.
Specialty Care Services
BCBSVT and TVHP define specialty care as services provided by
specialists (including obstetricians). The Department of Financial
Regulation (DOFR) require BCBSVT and TVHP to monitor specialists’
compliance with the standards described below. We use member
complaints, dis enrollments, appeals, member satisfaction surveys and
after‑hours telephone surveys to monitor compliance. The following
standards for access apply to care provided in an office setting:
•Appointments for non-urgent symptomatic office
visits must be available within two weeks.
•Appointments for emergency care (i.e., for accidental injury
or a medical emergency) must be available immediately in
the providers office or referred to an emergency facility.
If a provider does not meet one of the above standards, we work with
the provider to develop and implement an improvement plan.
Availability of Network Practitioners
The BCBSVT Quality Improvement Policy, Availability of Network
Practitioners provides the definition of the policy, including geographic
access, performance goals, travel time specifications, number of
practitioners, linguistic and cultural needs and preferences and how the
program is monitored. The policy is located on the secure provider portal
at www.bcbsvt.com under BCBSVT Policies then the Quality Improvement
link. Or, you can call your provider consultant for a paper copy.
Opening/Closing of Primary Care
Provider Patient Panels
Primary Care Services
Opening of a Closed Physician Panel: A PCP may open
his or her patient panel by sending a completed Provider
Enrollment/Change Form (PECF). If opening your patient
panel, be sure to include the date you wish to open your panel,
otherwise, we will use the date we received the form.
Closing of an Open Physician Panel: BCBSVT and TVHP require
60 days notice to close a patient panel. You must submit a Provider
Enrollment/Change Form. The effective date will be 60 days from
our receipt of the form. BCBSVT and/or TVHP will send confirmation
of our receipt of your request, including the effective date of the
change. A PCP may not close his or her panel to BCBSVT/TVHP
members unless the panel is closed to all new patients.
PCPs with closed patient panels: It is the PCP’s responsibility
to review the monthly managed care membership report. If a
member appears as an addition and is not an existing patient, notify
your provider relations consultant immediately. The notification
should contain the member ID number and name. We will
notify the member and ask him or her to select a new PCP.
If notification from the PCP does not occur within 30 days,
the PCP will be expected to provide health care until the
member is removed from the provider’s patient panel.
We will send confirmation to the provider that the
member has been removed and the effective date.
11
PCP Initiated Member Transfer
A Primary Care Provider may request to remove a BCBSVT, TVHP
and/or NEHP member from his or her practice due to:
•Repeated failure to pay co-payments, deductibles
or other out-of-pocket costs.
•Repeated missed scheduled appointments.
•Rude behavior or verbal abuse of office staff.
•Repeated and inappropriate requests for prior approval; or
•Irreconcilable deterioration of the physician/patient relationship.
The PCP must submit a written request to his or her provider relations
consultant clearly defining the reason, and documenting concerns,
regarding the deterioration of the patient/physician relationship,
and any steps that have been taken to resolve this problem.
The PCP should mail the letter to:
Attn: (your provider relations consultant’s name)
BCBSVT/TVHP
PO Box 186
Montpelier, VT 05601-0186
The provider relations consultant and the director of
provider relations will review each case, considering
provider and member rights and responsibilities.
If the transfer is approved, we will send a letter to the member
with a copy to the PCP. The member will be instructed to select a
new PCP who is not in the current PCP’s office. The current PCP is
expected to provide health care to the departing patient, as medically
necessary, until the new PCP selection becomes effective.
If we do not approve the transfer, we send the PCP a letter of explanation.
Transitioning Pediatric Patients
We know that transitioning your pediatric patient (of a certain age) to
their future provider for adult care, can be an emotional and sensitive
issue. We offer the following advice and tools to assist you:
•Talk with your patients who are approaching adulthood
about the need to select a primary care provider (PCP). Help them
to take the next step by recommending several providers. You
may even be able to provider some inisght into who may be a
good fit for them.
•Our Find a Doctor tool can help you or your patient identify
appropriate providers who are accepting new patients. To access
the Find a Doctor tool, go to the Blue Cross and Blue Shield of
Vermont website at www.bcbsvt.com and select the Find a Doctor
12
link. Once you accept the terms you can search by name, location,
specialty or specific gender of provider.
•Send a letter to your patients with a list of PCPs accepting
new patients. We offer a customizable letter you can use to help
highlight the importance of selecting a new provider and walk
the patient through the process. This template is available on our
provider webiste at www.bcbsvt.com.
•Encourage the patients to call BCBSVT directly at the
customer service number listed on the back of their identification
card for assistance in adding the new PCP to their member profile.
We also offer an online option they can use to update their PCP by
logging into our secure member portal at www.bcbsvt.com.
Notification of Change In Provider
and/or Group Information
Please complete a Provider Enrollment/Change Form
(PECF) for each of the following changes:
•Patient panel change (for managed care providers only)
•Physical, mailing or correspondence address
•Termination of a provider - or in place of a PECF, we will accept
an email for termination of a provider. Please see details
below in "Deleting/Terminating a Provider" section.
•Provider name (include copy of new license with new name)
•Provider specialty
•Change in rendering national provider identification number
Please complete a Group Practice Enrollment Change
Form (GPECF) for each of the following changes:
•Tax identification number (include updated W-9)
•Billing national provider identifier
•Physical, mailing or correspondence address
•Group Name
Mental Health and Substance Abuse Clinicians will need
to provide an updated Area of Expertise form if there is a
change in the type of conditions they are treating.
We cannot accept requests for changes by telephone.
If you have a change that is not on the list above, please provide
written notification on practice letterhead. Include with your written
documentation to BCBSVT and/or TVHP and the full names and NPI
numbers for the group and all providers affected by the change.
The forms (PECF, GPECF and Area of Expertise) are available our provider
website at www.bcbsvt.com under Forms, Enrollment and Credentialing.
If you are not able to access the web, contact provider enrollment at
(888) 449-0443 option 2 and a supply will be mailed out to you.
Mail your request to:
Provider File Specialist
BCBSVT
PO Box 186
Montpelier, VT 05601-0186
Or fax to: (802) 371-3489.
We appreciate your assistance in keeping our records and
provider directories up-to-date. Notifying us of changes ensures
that we continue to accurately process claims and that our
members have access to up-to-date directory information.
Note: Directory updates will occur within 30 calendar
days of receipt of notice of change.
Taxpayer Identification Number
If your Taxpayer Identification Number changes, you must provide
a copy of your updated W-9. We may need to update your provider
contract if your W-9 changes. For more information, please
contact your provider relations consultant at (888) 449-0443.
Provider Going on Sabbatical
Providers going on sabbatical for an indefinite time
period should suspend his/her network status.
Providers will notify their assigned Provider Relations Consultant of
when they are leaving and expected date of return. During the sabbatical
time period the provider will not be marketed in any directories and
will have members temporarily reassigned to another in-Plan provider
if a covering provider within their own practice is not identified.
Recredentialing will occur during the providers’ normal
recredentialing cycle. The provider should make arrangements to
ensure that the CAQH application and other information needed
for recredentialing is available and timely. If recredentialing
is not timely, the provider risks network termination.
Adding a Provider to a Group Vendor
Providers joining a group vendor must provide advance
notice to BCBSVT and/or TVHP. If the provider does not have
an active National Provider Identifier with BCBSVT/TVHP,
we need the following documents to add the provider:
•Provider Enrollment Change Form (PECF)
•Copy of current state licensure
•Any applicable Drug Enforcement Agency certificate (Please note that the
DEA for the state in which providers will be conducting business must
be supplied when dispensing, storing medications in that location.)
•Any applicable board certification
•Copy of a liability insurance
•Credentialing via the CAQH process, please see Enrollment of Providers
•Mental Health and Substance Abuse Clinicians must
complete the Area of Expertise form and attach
When we receive the required documentation, we will activate your
provider profile for both BCBSVT and TVHP. We will send a letter notifying
the provider of his or her addition to the group vendor file. The letter will
clarify the provider’s status with each network and effective date.
Provider Enrollment Change and/or Area of Expertise Forms are
available our provider website at www.bcbsvt.com under
Forms, Enrollment and Credentialing. If you are not able to
access the web, contact provider enrollment at (888) 449‑0443
option 2 and a supply will be mailed out to you.
Deleting/Terminating a Provider
A provider who leaves a group or private practice must provide advance
notice to BCBSVT. Notice can be provided through email to
[email protected] or by completing the "terminate provider"
section of the Provider Enrollment and Change Form (PECF). If you are
sending through email, you will want to include the provider's full name,
rendering national provider identifier (NPI), and if a group setting, the
NPI of the billing group, reason for termination (such as moved out of
state, went to another practice, going into private practice, etc.) and
termination date. If the terminating provider is a primary care provider,
we will need to know if there is another provider taking on those
patients. If submitting a PECF, follow the instruction on the form.
We appreciate your help in keeping our records up-to-date.
Notifying us in a timely manner of provider termination ensures
access and continuity of care for BCBSVT/TVHP members.
BCBSVT notifies affected members of a provider termination
30 days in advance of the effective date of termination.
You can download a Provider Enrollment/Change Form by logging onto
our provider site at www.bcbsvt.com. If you do not have internet access,
please contact your provider relations consultant for a copy of the form.
13
Utilization Management Denial
Notices: Reviewer Availability
We notify providers of utilization management (UM) denials by letter.
Providers are given the opportunity to discuss any utilization management
(UM) denial decision with a Plan physician or pharmacist reviewer.
All UM denial letters include the telephone number for our integrated
health management department. Providers may call this number if they
desire to discuss a UM denial with a Plan physician or pharmacist. The
telephone number is 1-800-922-8778 (option 4) or 1-802-371-3508.
Complaint and Grievance Process
Provider on Behalf of Member Appeal Process
supplied to BCBSVT during prior approval or claim submission process
are on file and will be automatically included in the appeal by BCBSVT.
•Grievances related to “urgent concurrent” services (services that are part of
an ongoing course of treatment involving urgent care and that have been
approved by us) will be decided within twenty-four (24) hours of receipt;
•Grievances related to urgent services that have not yet been provided
will be decided within seventy-two (72) hours of receipt;
•Grievances related to non-urgent mental health and substance abuse
services and prescription drugs that have not yet been provided
will be decided within seventy-two (72) hours of receipt;
•Grievances related to non-urgent services that have not yet been
provided (other than mental health and substance abuse services and
prescription drugs) will be decided within thirty (30) days of receipt; and
•Grievances related to services that have already been provided
will be decided within sixty (60) days of receipt.
An Appeal may only be filed by a provider on behalf of a Member
when there has been a denial of services which are benefit related
for reasons such as: non-covered services pursuant to the Member
Certificate; services are not medically necessary or investigational;
lack of eligibility; or, reduction of benefits. Before a provider on behalf of
member appeal is submitted, we recommend you contact the BCBSVT
Customer Service Department first, as most issues may be able to be
resolved, without an appeal. If you proceed with an Appeal there are
three levels to the Provider on behalf of Member Appeal process.
If the Provider on behalf Member Appeal is urgent, as described
above, you and the member will be notified by telephone and in
writing of the outcome. If the appeal is not urgent, as described
above, you and the member will be notified in writing of the
outcome. If you are not satisfied with the First Level Appeal
decision you may pursue the options below, if applicable.
Level 1—A First Level Provider on behalf of Member Appeal:
A Voluntary Second Level Appeal must be requested no later than
ninety (90) days after receipt of our first level denial notice. If we
have denied your request to cover a health care service, in whole
or in part, you as the provider on behalf of member, may request a
Voluntary Second Level Appeal at no cost to you or the member.
Level 1 outlines the information that should be included with your
appeal, review time frames, and where the appeal should be sent.
You and the member or the member’s authorized representative have
the opportunity to participate in a telephone meeting or an in‑person
meeting with the reviewer(s) for your second level appeal, if you wish.
If the scheduled meeting date does not work for you, or the member,
you may request that the meeting be postponed and rescheduled.
A first level Provider on behalf of Member Appeal must be filed in
writing to:
Blue Cross and Blue Shield of Vermont
Attn: Appeals
P.O. Box 186
Montpelier, VT 05601-0186
The appeal request may also be faxed to (802) 229-0511, Attn: Appeals.
The appeal request should include all supporting clinical information*
along with the Member certificate number, Member name, date of service
in question (if applicable), and the reason for appeal. Assuming you
have provided all information necessary to decide your grievance, the
appeal will be decided within the time frames shown below, based
on the type of service that is the subject of your appeal (grievance):
*Note: You only need to submit any supporting clinical information
that has not been previously supplied to BCBSVT. All medical notes, etc.,
14
Level 2—Voluntary Second Level Appeal
(not applicable to non group):
Level 3—Independent External Appeal:
A provider on behalf of member may contact the External Appeals
Program through the Vermont Department of Banking, Insurance,
Securities and Health Care Administration to submit an Independent
External Appeal no later than one hundred twenty (120) days after
receipt of our first level or voluntary second level, if applicable, denial
notice. If you wish to extend coverage for ongoing treatment for urgent
care services (“urgent concurrent” services) without interruption beyond
what we have approved, you must request the review within twenty‑four
(24) hours after you receive our first level or voluntary second level
denial notice. To make a request, contact the Vermont Department of
Banking, Insurance, Securities and Health Care Administration during
business hours (7:45 a.m. to 4:30 p.m., EST, Monday through Friday) at
External Appeals Program, Vermont Department of Banking, Insurance,
Securities and Health Care Administration, 89 Main Street, Montpelier, VT
05620‑3101, telephone: (800) 631-7788 (toll-free) or (802) 828-2900.
If your request is urgent or an emergency, you may call twenty-four
(24) hours a day, seven (7) days a week, including holidays. A recording
will tell you how to reach the person on call. If your request is not urgent,
the Department will provide you with a form to submit your request.
BlueCard Member Claim Appeal
An appeal request for a BlueCard member must be submitted in
writing using the BlueCard Provider Claim Appeal Form located on the
Provider Website under resources/forms/BlueCard Claim Appeal. If the
form is not submitted, the request will not be considered an Appeal.
The request will not be filed with the home plan but rather returned
to you. You will be informed of the decision in writing from BCBSVT.
Please note, the form requires the member’s consent prior to submission.
Some Blue Plans may also require the member to sign an additional
form, specific to their Plan, before starting the appeal process.
When a Member Has to Pay
If a member’s appeal is denied, they must pay for services we didn’t cover.
A: BCBSVT and/or TVHP has or had a relationship with the
individual who is the subject of such information; and
B: The Protected Health Information pertains to that relationship; and
C: The disclosure is for the purposes of:
•The Payment activities of BCBSVT and/or TVHP
•Conducting quality assessment or quality improvement
activities, including outcomes evaluation and development of clinical
guidelines
•Population-based activities relating to improving health or reducing
health care costs, protocol development, case management and care
coordination, contacting health care providers and patients with
information about treatment alternatives, and related activities that do
not include treatment
•Reviewing competence or qualifications of health care professionals,
evaluating practitioner and provider performance, health plan
performance
•Accreditation, certification, licensing, or credentialing activities
BCBSVT and/or TVHP will limit such requests for Protected
Health Information to the minimum amount of Protected Health
Information necessary to achieve the purpose of the disclosure.
Business Associates
Health Insurance Portability and
Accountability Act (HIPAA) Responsibilities
BCBSVT, TVHP, and its contracted providers are each individually
considered “Covered Entities” under the Health Insurance Portability and
Accountability Act Administrative Simplification Regulations (HIPAAAS) issued by the U.S. Department of Health and Human Services
(45 C.F.R. Parts 160-164). BCBSVT, TVHP and contracted providers shall,
by the compliance date of each of the HIPAA-AS regulations,
have implemented the necessary policies and procedures to comply.
For the purposes of this Section, the terms “Business Associate,”
“Covered Entity,”“Health Care Operations,”“Payment,” and “Protected Health
Information” have the same meaning as in 45 C.F.R. 160 and 164.
Disclosure of Protected Health Information
From time to time, BCBSVT or TVHP may request Protected Health
Information from a provider for the purpose of BCBSVT and/or TVHP
Payment and Health Care Operations functions, including but not limited
to the collection of HEDIS data. Upon receipt of the request, the provider
shall disclose, or authorize its Business Associate who maintains Protected
Health Information on its behalf to disclose the requested information
to BCBSVT/TVHP as permitted by the HIPAA-AS at § 164.506.
The provider is not required to disclose Protected Health Information unless
Providers are required to provide written notice to BCBSVT
or TVHP of the existence of any agreement with a Business
Associate, including, but not limited to, a billing service to
which Provider discloses Protected Health Information for the
purposes of obtaining Payment from BCBSVT and/or TVHP.
The notice to BCBSVT/TVHP regarding such
agreement shall, at a minimum, include:
•the name of the Business Associate
•the address of the Business Associate
•the address to which the BCBSVT and/or TVHP should remit
payment (if different than the Provider’s office)
•the contact person, if applicable
Upon receipt of notice, BCBSVT and/or TVHP will communicate
directly with Business Associate regarding Payment due to Provider.
Provider must notify BCBSVT and/or TVHP of the termination of the
Business Associate agreement in writing within ten (10) business days
of termination of the Business Associate agreement. BCBSVT/TVHP
shall not be liable for payment remitted to Provider’s Business Associate
prior to receipt of such notification. Notifications should be sent to:
Blue Cross and Blue Shield of Vermont
Attn: Privacy Officer
15
PO Box 186
Montpelier, VT 05601-0186
Standard Transactions
The provider and BCBSVT/TVHP shall exchange electronic transactions in the standard format required by HIPAA-AS. Questions regarding
the status of HIPAA Transactions with BCBSVT/TVHP should be directed to the E-Commerce Support Team at (800) 334-3441.
Member Rights and Responsibilities
Click here for full details and link to the URL:
http://www.bcbsvt.com/member/member-rights-responsibilities
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan Privacy Practices
We are required by law to maintain the privacy of our members’ health information by using or disclosing it only with the member’s authorization
or as otherwise allowed by law. Members have the right to information about our privacy practices. A complete copy of our Notice of Privacy
Practices is available at www.bcbsvt.com, or to request a paper copy, contact the Provider Relations Department at (888) 449-0443.
16
Section 2
Blue Cross and Blue Shield
of Vermont Web Site
The Blue Cross and Blue Shield of Vermont (BCBSVT) web site
located at www.bcbsvt.com/provider uses 128-bit encryption
as well as firewalls with built-in intrusion detection software. In
addition we maintain security logs that include security events
and administrative activity. These logs are reviewed daily.
Our provider website it broken out into two areas; a general area that
anyone can access and a secure area that only registered users can access.
The general area of the provider website contains information about
doing business with BCBSVT, such as recent provider mailing, news from
BCBSVT, forms, medical policies, provider manual, tools and resources.
The secure area of the provider website can only be accessed by
registered users and contains information such as eligibility, benefits
and claim status for BCBSVT, FEP and BlueCard members. To become
a registered user, you will need to work with your local administrator
(this is a person in your organization who has already agreed to oversee
the activities related to adding/deleting staff and assigning roles
and responsibilities for your organization). If your organization does
not already have a local administrator, click on the secure area of the
provider website and follow the instructions to register as a new user.
A complete demo on the BCBSVT provider website
is available by clicking this link:
www.bcbsvt.com/export/sites/BCBSVT/provider/
ProviderResourceCenter/bcbs_demo_2011.swf
Questions related to the website can be direct to the
provider relations team at (888) 449-0443
How to Review Coverage History on the Web:
The eligibiity functionality on the secure provider website does allow
providers to view previous BCBSVT coverage history for members for up
to 18 months as long as the member is still on an active BCBSVT policy.
If a member is terminated with BCBSVT you will not be
able to locate any eligiblity information on the web.
There are two ways to review previous membership. If you
know a member had previous coverage and is still active, you
can complete a search using either ID or name and change the
As of Date to the date of coverage you are looking for:
.
17
This will bring you to that member selection or a list of members, you just need to click on the
member you want to review (by clicking on their name highlighted in blue):
This will provide the details of the policy active during that time period, if you scroll to the bottom (titled
Benefit Plan Information), you will see the effective dates of that specific policy::
18
Or the second option, if you do not know if the member had previous coverage or not:
Enter the member’s identification number or name using the Eligibility/Benefits link it will automatically default to the current date::
Depending on how you search, you will either get a list or that specific member. Click on the
member’s name (highlighted in blue), this will bring you to the page below::
19
Click on View History, which will give you, if applicable a listing of previous dates of coverage:
If you want the specific details of the coverage and benefits, go back to the elligibility look up and change the As of date for the member.
20
Section 3
Member Accumulators
Members have specific dates when their deductibles,
out‑of‑pocket limits and other totals begin to accumulate
and run for a 12-month period before resetting. Our member
accumulators can be either on a calendar or plan year.
A calendar year schedule means that the deductible and
other benefit totals start to accumulate on January 1,
regardless of enrollment or renewal date.
Federal Employee Program. Full details on the BlueCard (Blue Plan
members) program are available in Section 8 of the provider manual.
Please note: BCBSVT is in the process of moving from Account
Numbers to Group Numbers for employer groups. During this
transition, you may find that the Group Number listed on a member’s
identification card is not the same number that appears during an
on-line eligibility look up or a HIPAA compliant 270/271 transaction.
When billing BCBSVT, you can report either number.
BCBSVT does not use this information when validating the
member’s coverage or eligibility for claim processing.
We anticipate the issue will be corrected in mid-2017.
We also have customer service teams that will be able to assist you over
A plan year shcedule means that the deductible and other benefit totals
start to accumulate on the effective or renewal date, which can be any time the phone if you are not able to utilize the web based searches. Click
here for a listing of contacts and number(s) to call for assistance.
of the year and run a 12-month period. They reset on the renewal date.
Examples of benefits affected by plan or calendar year
accumulators (this list may not be inclusive and in some
cases benefits may be limited to only certain products):
•Deductibles
•Out-of-pocket maximums
•Physical medicine, occupational therapy and/or speech therapy limits
•Chiropractic visit limit (before we require prior approval)
•Nutritional counseling visit limits
•Annual vision exam eligibility (if the member has the benefit)
•Private duty nursing
Vermont Health Connect members (those with federal
qualified health plans) which have a prefix of ZII (non-group)
or ZIG (small group) are based upon a calendar year.
Large group employers have the option to select a calendar
or plan year accumulators, so they will all vary.
It is very important when verifying eligibility that you aslo
verify when the members accumulators begin and reset.
Member Eligibility
Member eligiblity can be verified by using our Provider Resource Center
located at www.bcbsvt.com/provider. You must have a user name
and password to view the information. Full details on requirements
and how to obtain password are available on the “log in” page.
There are two web based options available; Eligibility Search and Realtime
Eligibility Search. The Eligibility Search feature will provide information
on members covered by BCBSVT. The Realtime Eligibility Search will
provide information on all Blue Plan members, including BCBSVT and
Regardless of which method you use to verify member
eligibility you will need to have key information available:
•Patient Name (First and Last)
•Patient Date of Birth (month, day and year)
•Patient identification number. For BCBSVT members this will include
an alpha prefix*, consisting of three letters and nine digiits, the first
one starting with an 8. For FEP members, the letter R which serves as
their prefix and eight digits. For BlueCard members, three letters which
will be their prefix, then the identification can be any length, be all
numbers, all letters or a combination of both letters and numbers.
And for a “real time” search in our provider resource
center, some additional information is required:
•Subscriber Name (First and Last)
•Subscriber Date of Birth (month, day and year)
•Requesting Provider (name of NPI#)
*Alpha prefix are not Blue Plan specific. For a listing of
BCBSVT, NEHP and CBA Blue prefixes, click here.
Member Certificate Exclusions
Our members’ certificates of coverage and riders contain a section
on general exclusions, which are services that, even if medically
necessary, are not eligible for reimbursement. Included among
these general exclusions are services prescribed or provided by a:
•Provider that we do not approve for the given service or that is not
defined in our “Definitions” section as a provider
•Professional who provides services as part of his or her education or
training program
•Member of your immediate family or yourself
•Veterans Administration Facility treating a service-connected disability
•Non-Preferred Provider if we require use of a Preferred Provider as a
21
condition for coverage under your contract
If you have questions regarding benefit exclusions, please contact our
customer service department, or your provider relations consultant.
Member Confidential Communications:
There are times, our members may not be in a safe
situation and require communications related to their
care be handled in a more sensitive manner.
For these situations, Blue Cross and Blue Shield of Vermont (BCBSVT)
members have the ability to file for a confidential communication process.
The below processes only apply to BCBSVT and the Vermont
Health Plan members. Members of any other Blue Plan
need to have requests filed with their home plans.
There are two types of confidential communication process:
•Standard Confidential Communication
•Confidential Communication for Sexual Assault (or other
expedited matters).
Standard Confidential Communication:
The member can use a Form F14: Confidential Communication request.
A copy of the form is available on our website at www.bcbsvt.com.
It is very important to include on the form or the fax cover sheet
a contact person’s name and direct phone number for BCBSVT to
follow up with questions or status on processing the request.
Confidential communications received for sexual assault
cases are expedited because of the nature of the services and
so that claims* don’t get submitted and processed before
BCBSVT gets the member’s explanation of benefits redirected or member resource center access revoked.
* Facilities and/or providers working with the members on this process
need to have a strong process in place to notify your billing staff and
have all claims submissions placed on hold until BCBSVT has confirmed
the process is complete and claim (s) are ready to be submitted.
For these expedited cases, the legal team will acknowledge
receipt of the forms to the submitter and confirm once
set up is complete so claims can be submitted.
Member Identification Cards
Blue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health
Plan (TVHP) issue identification cards to all members. Providers should
periodically ask to see the member’s identification card, and keep a
photocopy of it on file. Important information is often printed on the
back of the card, and in some cases, failure to comply with requirements
described on the card may result in a reduction of the member’s benefits.
Completed request forms for confidential communication can be faxed
directly to the BCBSVT legal department secure fax line at (866) 529-8503
or mailed to the attention of the privacy officer, BCBSVT, PO Box 186,
Montpelier, VT 05602 or faxed to our Customer Service department (802)
371-3658. The requests will be reviewed and processed within 30 days.
Please note: BCBSVT is in the process of moving from
Account Numbers to Group Numbers for employer groups.
Confidential Communication
for Sexual Assault:
When billling BCBSVT, you can report either number.
BCBSVT does not use this information when validating the
member’s coverage or eligibility for claim processing.
At times, Vermont S.A.N.E. (sexual assault nurse examiners) help
facilitate the confidential communication process for Vermont
sexual assault crime victims. The nurse may submit the Vermont
Center for Crime Victim Services confidential communication
form or the BCBSVT confidential communication form.
These requests can be submitted using Form F14: Confidential
Communication or the Vermont Center for Crime Victim Services
Confidential Communication form. If you are using Form F14, you will
want to make sure you clearly note it is related to sexual assault.
They need to be faxed to the Legal Department (866) 529-8503
or the Customer Service department (802) 371-3658.
22
During this transition, you may find that the Group Number listed on a
member’s identification card is not the same number that appears during
an on-line eligibility look up or a HIPAA compliant 270/271 transaction.
New identification cards are issued to members
whenever there is a change in:
•Benefits
•Membership
•Primary Care Provider (for managed care members)
Below you will find sample cards from each product we offer.
The easy-to-find alpha prefix identifies the
member’s Blue Cross and Blue Shield Plan.
The BlueCard suitcase logo may appear
anywhere on the front of the ID card.
groupNumber:
BC/BSPLAN:
Rxgroup:
EffectiveDate:
PREVENTIVE
PCP
SPECIALIST
SPECIALISTACCTBLUE
EmERgENCyRoom
123456789
415/915
VT7A
mm/dd/yyyy
$ 0
$XX
$XX
$XX
$XX
Accountable Blue
ACP 101/ ACP 102
Accountable
Blue
Subscriber
John 
Subscriber
ID:ZIA123456789
member 03
Jane Smith
PrimaryCarePhysician:
J Q Careprovider
groupNumber:
BC/BSPLAN:
Rxgroup:
EffectiveDate:
PREVENTIVE
PCP
SPECIALIST
SPECIALISTACCTBLUE
EmERgENCyRoom
123456789
415/915
VT7A
mm/dd/yyyy
PleaserefertoyourContractforcomplete
information.
$ 0
$XX
$XX
$XX
$XX
Priorapprovalisnecessaryforcertain
proceduresandprescriptiondrugs.
Visitwww.bcbsvt.comorcallcustomer
serviceforthelistandinstructions
forrequestingpriorapproval.
yourAccountableBlueTeam(AcctBlue)
includestheCVmCmedicalStaff
alongwithothercentralVermont
providers.Foracompletelisting,
visitwww.bcbsvt.com/acctblue.
www.bcbsvt.com
[email protected]
CustomerService: (800) 344-6690
ProviderService: (800) 924-3494
outsideofArea: (800) 810-2583
mentalHealthand
SubstanceAbuseTreatment
PriorApproval:
(800) 395-1356
Pharmacy:
(877) 493-1947
Blue Cross and Blue Shield of Vermont
P.o.Box186
montpelier,VT05601-0186
An Independent licensee of the
Blue Cross and Blue Shield Association.
Pharmacybenefitsmanager
ACP 101/ ACP 102
Blue Card
www.bcbsvt.com
[email protected]
CustomerService: (800) 344-6690
ProviderService: (800) 924-3494
outsideofArea: (800) 810-2583
mentalHealthand
SubstanceAbuseTreatment
PriorApproval:
(800) 395-1356
Pharmacy:
(877) 493-1947
See Section 7 for a sample BlueCard ID card.
PleaserefertoyourContractforcomplete
information.
Priorapprovalisnecessaryforcertain
proceduresandprescriptiondrugs.
Visitwww.bcbsvt.comorcallcustomer
serviceforthelistandinstructions
forrequestingpriorapproval.
yourAccountableBlueTeam(AcctBlue)
includestheCVmCmedicalStaff
alongwithothercentralVermont
providers.Foracompletelisting,
visitwww.bcbsvt.com/acctblue.
Blue Cross and Blue Shield of Vermont
P.o.Box186
montpelier,VT05601-0186
An Independent licensee of the
Blue Cross and Blue Shield Association.
Comp
Plan
Subscriber
John
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Member 03
Jane Smith
123456789
415/915
VT7A
mm/dd/yyyy
Indemnity (Fee-for-Service)
Pharmacybenefitsmanager
Comp 301/Comp 102
Comp
Plan
Subscriber
John
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Refer to your Contract for complete
information.
Member 03
Jane Smith
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
123456789
415/915
VT7A
mm/dd/yyyy
Prior approval is necessary for
certain procedures and prescription
drugs. Visit www.bcbsvt.com or
call customer service for the list
Subscriber
and instructions for requesting prior
John
approval.
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
12345678
415/915
VT7A
mm/dd/yyyy
www.bcbsvt.com
[email protected]
Customer Service: (800) 247-2583
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Inpatient Preadmission/
Admission Review: (800) 922-8778
Mental Health and
Substance Abuse Treatment
Prior Approval:
(800) 395-1356
Pharmacy: Open (877) 493-1947
Access
Blue Cross andPlan
Blue Shield of Vermont
P.O. Box 186
Member
0305601-0186
Montpelier, VT
An independent
Jane
Smith licensee of the
Blue CrossCare
and Blue
Shield Association.
Primary
Physician:
J Q Careprovider
Pharmacy benefits manager
Office Visit:
$20
Comp 301/Comp 102
www.bcbsvt.com
[email protected]
Customer Service: (800) 247-2583
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Inpatient Preadmission/
Admission Review: (800) 922-8778
Mental Health and
Substance Abuse Treatment
Prior Approval:
(800) 395-1356
Pharmacy: Open (877) 493-1947
University of Vermont Open Access Plan
Refer to your Contract for complete
information.
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Prior approval is necessary for
certain procedures and prescription
drugs. Visit www.bcbsvt.com or
call
customer service for the list
Subscriber
and
Johninstructions for requesting prior
approval.
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
12345678
415/915
VT7A
mm/dd/yyyy
Access
Blue Cross and Plan
Blue Shield of Vermont
P.O. Box 186
Member VT0305601-0186
Montpelier,
An
independent
Jane
Smith licensee of the
Blue
CrossCare
and Blue
Shield Association.
Primary
Physician:
J Q Careprovider
Pharmacy benefits manager
Office Visit:
$20
UVM 501/ UVM 102
www.bcbsvt.com
[email protected]
(888) 222-7886
(888) 222-7886
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Prior Approval:
(888) 222-7886
Report a hospital admission
or surgery:
(888) 222-7886
Pharmacy:
(877) 493-1950
– PageCustomer
1 – Service:
Provider Service:
Refer to your Contract for complete
information.
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Prior approval is necessary for certain
procedures and prescription drugs.
Visit www.bcbsvt.com or call customer
service for the list and instructions for
requesting prior approval.
Blue Cross and Blue Shield of Vermont
P.O. Box 186
Montpelier, VT 05601-0186
An Independent licensee of the
Blue Cross and Blue Shield Association.
Pharmacy benefits manager
UVM 501/ UVM 102
www.bcbsvt.com
[email protected]
(888) 222-7886
(888) 222-7886
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Prior Approval:
(888) 222-7886
Report a hospital admission
or surgery:
(888) 222-7886
Pharmacy:
(877) 493-1950
– Page Customer
1 – Service:
Provider Service:
Refer to your Contract for complete
information.
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Prior approval is necessary for certain
procedures and prescription drugs.
Visit www.bcbsvt.com or call customer
service for the list and instructions for
requesting prior approval.
Blue Cross and Blue Shield of Vermont
P.O. Box 186
Montpelier, VT 05601-0186
An Independent licensee of the
Blue Cross and Blue Shield Association.
Pharmacy benefits manager
– Page 1 –
23
BC/BS PLAN:
Rx Group:
Effective Date:
415/915
VT7A
mm/dd/yyyy
Vermont Blue 65 (formerly known as Medi-Comp)
FMEDI - LMEDI1 - BMEDI
Vermont
Blue 65
Subscriber
John
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Member 03
Jane Smith
Refer to your Contract for complete
information.
www.bcbsvt.com
[email protected]
Customer Service: (800) 247-2583
Provider Service: (800) 924-3494
Pharmacy:
(877) 493-1947
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
12345678
415/915
VT7A
mm/dd/yyyy
Blue Cross and Blue Shield of Vermont
P.O.
Box 186 03
Member
Montpelier,
VT 05601-0186
Jane Smith
An independent licensee of the
Blue Cross and Blue Shield Association.
Subscriber
John
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Vermont
Freedom
Plan
123456789
415/915
VT7A
mm/dd/yyyy
OffICE benefits
VISIT manager
$20
Pharmacy
EMERGENCy
$50
FMEDI - LMEDI1 - BMEDI
Vermont Freedom Plan PPO (VFP)
Refer to your Contract for complete
information.
www.bcbsvt.com
[email protected]
Customer Service: (800) 247-2583
Provider Service: (800) 924-3494
Pharmacy:
(877) 493-1947
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Vermont
Freedom
PlanShield of Vermont
Blue Cross and Blue
P.O. Box 186
Member VT03
Montpelier,
05601-0186
Jane
Smith licensee of the
An
independent
Blue Cross and Blue Shield Association.
Subscriber
John
Subscriber
ID: XYZ123456789
123456789
415/915
VT7A
mm/dd/yyyy
Free 101/Free 202
Pharmacy benefits manager
OffICE VISIT
$20
EMERGENCy
$50
www.bcbsvt.com
[email protected]
(800) 247-2583
(800) 924-3494
Outside of Area:
(800) 810-2583
Inpatient Preadmission/
Admission Review: (800) 922-8778
Pharmacy:
(877) 493-1947
The Vermont
Health
Plan
Customer
– Page 28
– Service:
Provider Service:
Refer to your Contract for complete
information.
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Subscriber
John
Subscriber
ID: XYZ123456789
Member 03
Blue Cross and Blue Shield of Vermont
Jane Smith
P.O. Box 186
Primary
Care
Montpelier,
VT Physician:
05601-0186
JAn
Q independent
Careprovider
licensee of the
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
PREVENTIVE OffICE
OffICE VISIT
Pharmacy benefits manager
SPECIALIST
INPATIENT HOSPITAL
OuTPATIENT SuRGERy
EMERGENCy ROOM
Blue Cross and Blue Shield Association.
123456789
415/915
VT7A
mm/dd/yyyy
$0
$20
$30
$500
$200
$100
Free 101/Free 202
The Vermont Health Plan (TVHP)
www.bcbsvt.com
[email protected]
– Page 28
– Service: (800) 247-2583
Customer
Refer to your Contract for complete
information.
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Subscriber
John
Subscriber
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Rx Group:
Effective Date:
Member 03
Blue Cross
Jane
Smithand Blue Shield of Vermont
P.O. Box 186
Primary
Care Physician:
Montpelier, VT 05601-0186
JAn
Qindependent
Careprovider
licensee of the
123456789
415/915
VT7A
mm/dd/yyyy
TVHP 101/TVHP 102
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Inpatient Preadmission/
Admission Review: (800) 922-8778
The Vermont
Pharmacy:
(877) 493-1947
Health
Plan
Blue Cross and Blue Shield Association.
PREVENTIVE OffICE
OffICE VISIT
Pharmacy benefits manager
SPECIALIST
INPATIENT HOSPITAL
OuTPATIENT SuRGERy
EMERGENCy ROOM
$0
$20
$30
$500
$200
$100
Please refer to your Contract for
complete information.
– Page 6 –
All services delivered outside The Vermont
Health Plan’s network require Prior
Approval. you do not need Prior Approval
if your condition meets our definition of an
Emergency Medical Condition.
Subscriber
Providers
John outside Vermont should file
claims
with their local Blue Cross and
Subscriber
Blue
Shield Plans.
ID: XYZ123456789
Group Number:
BC/BS PLAN:
Effective Date:
www.bcbsvt.com
[email protected]
Customer Service: (888) 882-3600
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Vermont(800) 395-1356
Prior Approval:
Pharmacy: Health (877) 493-1947
123456789
415/915
mm/dd/yyyy
Partnership
The Vermont Health Plan*
isMember
a controlled03
affiliate of
Blue
and Blue Shield of Vermont*
JaneCross
Smith
P.O. Box 186
Primary Care Physician:
Montpelier, VT 05601-0186
Q Careprovider
*JIndependent
licensees of the
Blue Cross and Blue Shield Association.
OffICE VISIT
SPECIALIST
INPATIENT
HOSPITAL
Pharmacy
benefits
manager
OuTPATIENT SuRGERy
EMERGENCy ROOM
$10
$20
$250
$100
$50
TVHP 101/TVHP 102
Vermont Health Partnership (VHP)
Please refer to your Contract for
complete information.
Subscriber
Providers outside Vermont should file
John
claims with their local Blue Cross and
Subscriber
BlueXYZ123456789
Shield Plans.
ID:
123456789
415/915
mm/dd/yyyy
Partnership
The Vermont Health Plan*
is
a controlled03
affiliate of
Member
Blue Cross and Blue Shield of Vermont*
Jane Smith
P.O. Box 186
Primary
Care
Physician:
Montpelier, VT 05601-0186
Q Careprovider
*JIndependent
licensees of the
Blue Cross and Blue Shield Association.
OffICE VISIT
SPECIALIST
INPATIENT
HOSPITAL
Pharmacy
benefits
manager
OuTPATIENT SuRGERy
EMERGENCy ROOM
$10
$20
$250
$100
$50
VHP 201/ VHP 202
24
Please refer to your Contract for
complete information.
VHP 201/ VHP 202
– Page 6 –
All services delivered outside The Vermont
Health Plan’s network require Prior
Approval. you do not need Prior Approval
if your condition meets our definition of an
Emergency Medical Condition.
Group Number:
BC/BS PLAN:
Effective Date:
www.bcbsvt.com
[email protected]
Customer Service: (888) 882-3600
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Prior Approval:
Vermont(800) 395-1356
Pharmacy: Health (877) 493-1947
www.bcbsvt.com
[email protected]
Customer Service: (800) 344-6690
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Prior Approval:
(800) 395-1356
– Page 10 –
Providers outside Vermont should file
claims with their local Blue Cross and
Please refer to your Contract for
complete information.
www.bcbsvt.com
[email protected]
Customer Service: (800) 344-6690
Provider Service: (800) 924-3494
Outside of Area:
(800) 810-2583
Mental Health and
Substance Abuse Treatment
Prior Approval:
(800) 395-1356
– Page 10 –
Providers outside Vermont should file
claims with their local Blue Cross and
Blue Shield Plans.
Prior approval is necessary for certain
procedures. Visit www.bcbsvt.com or
call customer service for the list and
instructions for requesting prior approval.
Blue Cross and Blue Shield of Vermont
P.O. Box 186
Montpelier, VT 05601-0186
An Independent licensee of the
Blue Cross and Blue Shield Association.
Member Proof of Insurance
Members who are new to BCBSVT or existing members that have a change in their membership status (such as change in benefit plan, addition
of member to policy, etc.) are able to print a “proof of insurance” document from the member website. Below is an example of this document.
This document serves as proof of insurance until the identification card is received by the member. It provides the details your practice will need
to verify a member’s eligibility and benefits on the secure provider website at www.bcbsvt.com or by calling the customer service team
.
Dear, NAME
NAME: <Bookmark First and Last Name>
DOB: 00/00/0000
MEMBER ID: USID
GROUP: <Bookmark Group Name>
GROUP NO: <Bookmark Group Number>
PLAN CODE: 415/915
PHARMACY: Details provided in table below
Certification of Health Plan Coverage
If you don’t have your ID card, you may use this form as temporary proof of coverage, subject to the
terms and conditions of your Certificate of Coverage and your contract documents.
1. Name(s) of any members to whom this certificate applies:
Member Name
Coverage Start Date
Coverage End Date
2. Name and address of plan administrator or insurer responsible for providing this certificate:
Blue Cross Blue Shield of Vermont
P.O. Box 186
Montpelier, VT 05601-0186
3. Customer Service Team: (800) 247-2583
4. Pre-Admission Review: (800) 922-8778
PHARMACY DETAILS: Your pharmacist can use the information in the table below to fill your prescriptions before you receive your ID card.
Please note, if you have Medicare Part D coverage, your group may have elected you to have your benefits
managed by Blue MedicareRxSM. Please see your separate pharmacy ID card.
If Prefix is
DVT, EVT, FVT, FAC, FAH, FAO
ZIB
ZIA, ZID, ZIE, ZIF, ZIH, ZIJ, ZIK, ZIL, ZIU, ZIV,
ZIG, ZII
Pharmacy Group Number is
See pharmacy ID card
VT7A (Express Scripts) - Discount only
VT7A (Express Scripts)
L4FA (Express Scripts)
Contact Number
See pharmacy ID card
(877) 493-1947
(877) 493-1947
(877) 493-1947
If your coverage has ended and you wish to get new coverage, there may be a time limit on when you may do so without
being required to wait for an open enrollment period. This period of time can be as little as 30 days from the triggering event causing
you to lose coverage. For more information about special enrollment periods and applicable deadlines, please contact:
•your new employer, if you will get your coverage through work; or
25
•Vermont Health Connect, if you will purchase coverage outside of work (855) 899-9600.
You can use this form for proof of coverage, if your new coverage requires
that you had previous coverage within a certain time period.
If you have questions or concerns, you may contact our customer service team
toll-free at (800) 247-2583. We’re in the office Monday through Friday from 7 a.m. to
6 p.m., except holidays. You may also send us a secure message through our Member
Resource Center online by logging into your account at www.bcbsvt.com/MRC.
Thank you for choosing Blue Cross and Blue Shield of Vermont for your
health and wellness benefits. We look forward to serving you.
26
Section 4
Medical Utilization Management
(Care Management)
The Blue Cross and Blue Shield of Vermont integrated
health management department performs focused medical
utilization review for selected inpatient and outpatient services.
Medical utilization management is part of the overall Blue Cross and
Blue Shield of Vermont care management program.
The focused inpatient utilization is based on an analysis of the individual
hospital’s utilization and practice patterns, and may vary by provider.
Utilization patterns at the network hospitals are reviewed quarterly.
As utilization patterns change, the Plan evolves the focus of the inpatient
utilization review process. Clinicians conduct telephonic review on
those inpatient cases that meet the focus criteria for that quarter.
Integrated health management staff also review targeted outpatient
procedures and services through the prior approval process.
Clinicians are authorized to grant approval for services that
meet plan guidelines, and deny services excluded from the
benefit plan. A plan physician makes all denial decisions
that require an evaluation of medical necessity.
Components of the medical utilization management program include:
•Pre-notification of admissions
•Prior approval/Pre-service
•Concurrent review
•Retrospective review/Post-service
•Discharge planning in collaboration with facilities, members and providers
•Medical claim review
BCBSVT provides members, providers and facilities access to a tollfree number for utilization management review. The utilization
management staff of the integrated health management department
is available to receive and place calls during normal business hours
(8 a.m. to 4:30 p.m., Monday through Friday). Integrated health
management staff do not place outgoing calls after normal business
hours. In addition, members and/or providers who need to contact the
Plan after normal business hours may utilize the toll free number and
leave a voice message related to non‑urgent/non-emergent care that is
reviewed the next business day for appropriate disposition. Information
may be sent via fax or Web at any time, with the ability to attach clinical
information with the request, but if sent after hours, it is addressed the
next business day. For urgent or emergent care, a clinician and physician
are available to providers (by toll free telephone number) 24 hours a
day, seven days a week to render utilization review determinations.
When speaking with others, the integrated health management staff
identify themselves by name, title and as an employee of Blue Cross and
Blue Shield of Vermont. All inquiries related to specific UM cases are
forwarded to integrated health management staff for resolution,
regardless of where the initial inquiry was received within the Plan.
Case managers collect data on all case managed cases,
including the following:
•Age of member
•Previous medical history and diagnosis
•Signs and symptoms of their illness and co-morbidities
•Diagnostic testing
•The current plan of care
•Family support and community resources
•Psychosocial needs
•Home care needs if appropriate
•Post hospitalization medical support needs including durable medical
equipment, special therapy, and medications/infusion therapy
The following information sources are considered when
clinicians perform utilization management review:
•Primary care provider and/or attending physician
•Member and/or family
•Hospital medical record
•Milliman Health Care Management Guidelines, Inpatient and
Surgical Care and Ambulatory, and Recovery Facility Guidelines
•Blue Cross and Blue Shield of Vermont medical policies
•Blue Cross and Blue Shield Association medical policies
•Board certified specialist consultants
•TEC (Technology Evaluation Center) assessment
•Health care providers involved in the member’s care
•Hospital clinical staff in the utilization and quality assurance departments
•Plan medical director and physician reviewers
A more intensive review occurs for some requested procedure/
service(s) based on the need to direct care to specific providers, coverage
issues, or based on quality concerns about the medical necessity
for the requested procedure/service(s). A more intensive review
may require office records and/or additional medical information
to support the request. The services which require additional
medical information include, but are not limited to:
•Possible cosmetic procedures, e.g. breast reduction
•Organ transplants
•Out-of-network for point of service product(s) and managed products
•Experimental procedures/protocols
Individual member needs and circumstances are always considered when
making UM decisions, and are given the greatest weight if they conflict
27
with utilization management guidelines. In addition, both behavioral
and medical staff consider the capability of the Vermont health care
system to actually deliver health services in an alternate (lesser) setting
when applying utilization management criteria. If the requested services
do not meet the Plan’s criteria, clinical staff documents the member’s
clinical needs and circumstances, and any limitations in the delivery
system and forward that information to a medical director for a decision.
(LOCUS), Child and Adolescent Level of Care Utilization (CALOCUS)
and the American Society of Addiction Medicine (ASAM) criteria.
Utilization Review Process
The Blue Cross and Blue Shield Association Medical Policy Manual provides
an informational resource which, along with other information, a member
Blue Cross and Blue Shield plan (and its licensed affiliates) may use to:
•Administer national accounts as they may decide to have
their employee benefit coverage so interpreted.
•Assist the Plan in reaching its own decisions on matters of
subscriber coverage and related medical policy, utilization
management, managed care and quality assessment programs.
The utilization review clinician may contact the facility utilization
review staff and/or the attending provider to obtain the clinical
information needed to approve services. However, if the utilization
review nurse cannot obtain sufficient information to determine the
medical necessity, appropriateness, efficacy, or efficiency of the service
requested, and/or the review is unresolved for any other reason, the
Plan’s clinical reviewer refers the case to a Plan provider reviewer.
The Plan’s provider reviewer considers the individual clinical
circumstances and the capabilities of the Vermont community
delivery system for each case. In making the final determination,
the actual clinical needs take precedence over published review
criteria. In the event of an adverse decision, both the member and
participating provider can request an appeal. The appeal procedure
is documented more specifically later in this document.
During the concurrent review process, if services or treatments are provided
to the member that were not included in the original request, and are
determined to be not medically necessary, the Plan may deny those
services or treatments and the member is not to be held liable. This means
that the member is not penalized for care delivered prior to notification
of an adverse determination. For further details see provider contracts.
BCBSVT utilization staff will not accept any financial
incentive relating to UM decisions.
Clinical Practice Guidelines
The BCBSVT Quality Improvement Policy, Clinical Practice Guidelines
provides the details on the policy, policy application and annual review
criteria. The policy is located on the secure provider portal at
www.bcbsvt.com under BCBSVT Policies, then the Quality Improvement
link. Or, you can call your provider consultant for a paper copy.
Clinical Review Criteria
The Plan utilizes review guidelines that are informed by generally
accepted medical and scientific evidence and consistent with clinical
practice parameters as recognized by health professionals in the same
specialties as typically provide the procedure or treatment, or diagnose
or manage the medical condition. Such guidelines include nationally
recognized health care guidelines, MCG, Level of Care utilization System
28
In addition to the national guidelines mentioned above, the Plan’s
internal medical policy and the Blue Cross and Blue Shield Association
Medical Policy and/or the TEC Assessment Publications are
utilized as resources to reach decisions on matters of medical
policy, benefit coverage and utilization management.
These guidelines are reviewed on an annual basis by the clinical
advisory committee to assure relevance with current practice, taking
into account input from practicing physicians, psychiatrists, and other
health providers, including providers under contract with the Plan, if
applicable, and are available to all providers under contract with the
Plan, as well as to members and their treating providers upon request.
Providers and members may request a copy of the applicable
criteria from the integrated health management department by
facsimile (802) 371-3491, phone (800) 922-8778, option 1, or
mail at BCBSVT, PO Box 186, Montpelier, VT 05601‑0186.
The Plan has adopted the nationally recognized guidelines
for the treatment of Congestive Heart Failure, Chronic
Obstructive Pulmonary Disease, Substance Use Disorders
Clinical Practice Guidelines
•Evaluation and Management of Congestive Heart Failure in
the Adult, American College of Cardiology and American
Heart Association: www.cardiosource.org/
•Global Initiative for Chronic Obstructive Lung Disease—a
Pocket Guide to COPD Diagnosis, Management and Prevention,
a Guide for Health Care Professionals: www.goldcopd.org/
•Treating Patients with Substance Use Disorders, Alcohol,
Cocaine and Opioids, American Psychiatric Association:
www.psychiatryonline.com/pracGuide/pracGuideTopic_5.aspx
•Treating Major Depression, American Psychiatric Association:
www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx
The Plan has adopted nationally recognized preventive health and clinical
practice guidelines for Adult and Pediatric Preventive Immunizations,
Adult and Children and Adolescent Clinical Preventive Services, and
treatment of Substance Abuse, Opioid Abuse, and Depressive Disorder.
Nationally recognized experts developed these guidelines. The guidelines
are available for you to read or print on the following websites:
•Adult Preventive Immunization, Centers for Disease Control and
Prevention: www.cdc.gov/vaccines/schedules/hcp/adult.html
•Pediatric Preventive Immunizations, Centers for Disease Control and
Prevention: www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
•USPSTF Recommended Adult Preventive
Guidelines, U.S. Preventive Services Task Force:
www.uspreventiveservicestaskforce.org/uspstopics.html
•USPSTF Recommended Preventive Guidelines for Children
and Adolescents, U.S. Preventive Services Task Force:
www.uspreventiveservicestaskforce.org/tfchildcat.html
•Guidelines for the Treatment of Patients with Substance
Abuse, Opioid Abuse, American Psychiatric Association:
http://psychiatryonline.org/guidelines.aspx
•Guidelines for Treatment of Patients with Depressive Disorder, American
Psychiatric Association: http://psychiatryonline.org/guidelines.aspx
In addition to the nationally recognized preventive health and clinical
practice guidelines listed above, BCBSVT bi-annually adopts new
clinical practice guidelines and reviews clinical guidelines that the
Plan previously adopted. The Plan has adopted guidelines for the
treatment of Chronic Heart Failure, Chronic Obstructive Pulmonary
Disease, Diabetes, Asthma, Overweight and Obesity, and Hypertension.
The guidelines may be evidence-based guidelines or consensus
guidelines developed by providers. These guidelines are available at
www.bcbsvt.com/provider/reference-guides/clinical-practice-guides,
by calling Customer Service at (800) 924-3494 or by
emailing [email protected].
Advanced Benefit Determination
Federal Employee Program (FEP) members are entitled to
BCBSVT reviewing and responding to “Advanced Benefit
Determinations”. This allows members and providers to submit
a request in writing asking for benefit availability for specific
services and receive a written response on coverage.
You can use the prior approval form for submission of FEP advanced
benefit determinations, but you will need to clearly mark on the
form (preferably at the top) “Advanced Benefit Determinations”.
If the prior approval form is not clearly marked, it will be
assumed you are submitting for prior approval only.
Prior Approval/Referral Authorization (referral authorizations
are only required for members with the New England Health Plan)
Prior approval/referral authorization is required for coverage of selected
supplies, procedures, and pharmaceuticals before services are rendered, as
outlined in member certificates and outlines of coverage. Even members
with BCBSVT/TVHP as a secondary carrier, including those with Medicare
as the primary carrier, need to obtain a prior approval for applicable
services. These lists are updated annually based upon Vermont practice
patterns. The current lists are available on the provider resource center
located at www.bcbsvt.com. Requests for prior approval/referral
authorization can be submitted by phone, mail, fax or Web to Integrated
Health Management at the Plan utilizing the appropriate form for
supplies and procedures, or pharmaceuticals. These prior approval/referral
authorization requests may come from the referring provider, the servicing
provider or the member. Forms can be obtained from the provider resource
center located at www.bcbsvt.com or by calling customer service.
Note: Referral authorizations for members with New England Health
Plan should only be sent to BCBSVT if the member has selected a
primary care provider located in the State of Vermont. If the member
has selected a PCP in any other state, the local Blue Cross and Blue
Shield Plan’s prior approval/referral authorization guidelines will
apply and requests need to be submitted directly to that Plan.
Prior approval/referral authorization requests are reviewed by
a Plan clinician, a Plan/TVHP medical director, a Plan contract
dentist reviewer, a Plan pharmacist reviewer, or a Care Advantage
Inc., (CAI) consultant medical director. The clinician may approve
services but does not issue medical necessity denials. The dentist
and pharmacist reviewers’ only review requests pertinent to their
disciplines. Determinations to deny or limit services are only made
by physicians under the direction of the medical director.
Upon receipt, the reviewer evaluates the prior approval request.
If insufficient information is present for determination, additional
information is requested, in writing, from the member or provider.
The notice of extension specifically describes the required information.
The member or provider is afforded at least 45 calendar days from
receipt of the notice within which to provide the specified information,
or the Plan will deny the request for benefits as not medically
necessary based on the information received, and the charges may
be denied when claims are submitted without prior approval.
A complete list of services requiring prior approval for FEP members
is available on our provider website at www.bcbsvt.com/provider
under the Prior Approval/Pre-Notification/Pre-Service request link.
29
Once the information is sufficient for determination, the registered
clinical reviewer approves requests that meet pre-established medical
necessity criteria and are covered benefits. If medical necessity criteria
are not met, the registered clinical reviewer refers the case to a Plan
medical director for decision. The physician reviewer may request
additional information or contact the requesting physician directly to
discuss the case. Appropriate clinical information is collected and a
decision formulated based on adherence to nationally accepted treatment
guidelines and unique individual case features. References used to
make determination include, but are not limited to the following:
•Blue Cross and Blue Shield Association TEC Assessment
•Blue Cross and Blue Shield Association Medical Policy Manual
•Blue Cross and Blue Shield of Vermont Medial Policy Manual
•Medical director review of current scientific literature
•Review of specific professional medical and
scientific organizations, (i.e. SAGES)
•Milliman, Current Edition
Once a determination is made, the member, provider and
the referred-to-provider are notified in writing for approvals
and denials. Decision letters contain the following:
•A statement of the reviewers understanding of the request;
•If applicable, a description of any additional material or information
necessary for the member to perfect the request and an
explanation of why such material or information is necessary;
•If the review resulted in authorization, a clear and complete description of
the service(s) that were authorized and all applicable limits or conditions;
•If the review resulted in adverse benefit determination, in whole or in part;
•The specific reason for the adverse benefit determination, in easily
understandable language
•The text of the specific health benefit plan provisions
on which the determination is based;
•If the adverse benefit determination is based on medical necessity,
an experimental/investigational exclusion, is otherwise an appealable
decision or is otherwise a medically-based determination: an explanation
of the scientific or clinical judgment for the determination, and
an explanation of how the clinical review criteria and the terms of
the health benefit plan apply to the member’s circumstances;
•If an internal rule, guideline, protocol, or other similar criterion was relied
upon in making the adverse benefit determination, either the specific
rule, guideline, protocol, or other similar criterion; or a statement that
such a rule, guideline protocol, or other similar criterion was relied upon
in making the adverse benefit determination and that a copy of such rule,
guideline or protocol or other criterion will be provided to the member
upon request and free of charge within two business days or, in the case
of concurrent or urgent pre-service review, immediately upon request;
•If the review is concurrent or pre-service, what, if any,
alternative covered benefit(s) the Plan will consider to be
medically necessary and would authorize if requested;
•A description of grievance procedures and the time
limits applicable to such procedures;
•In the case of a concurrent review determination or an urgent,
pre‑service request, a description of the expedited grievance
review process that may be applicable to such requests;
•A description of the requirements and timeframes for filing grievances
and/or a request for independent external review in order for the member
or provider to be held harmless pending the outcome, where applicable;
•Notice of the right to request independent external review
after a grievance determination, in the language, format
and manner prescribed by the Department; and
•Local and toll free numbers for the department’s health care consumer
assistance section and the Vermont Office of Health Care Ombudsman
For all lines of business, the Plan adheres to Vermont Rule H2009-03,
NCQA accreditation, and federal timeliness standards. For non‑urgent
pre-service review decisions, the Plan must provide written notice
of adverse determination to the member and treating provider
(if known), within a reasonable period, not longer than two
business days after receipt of the request. Verbal notification must
be given to the member and treating provider (if known) with
written notification sent within 24 hours of verbal notification.
If additional information is needed because of lack of information
submitted with the prior approval request, the Plan sends a written
request for additional information within two business days of receipt
of the request. The notice of extension specifically describes the required
information. The member or provider has at least 45 calendar days from
receipt of the notice within which to provide the specified information.
The Plan does not retroactively deny reimbursement for services that
received prior approval, except in cases of fraud including material
misrepresentation. See provider contracts for more complete details.
Note: Dental prior approval for (1) Health Exchange pediatric
members or (2) members of an administrative services only (ASO)
whose employer group has purchased dental coverage through BCBSVT
and are eligible through the BCBSVT Dental Medical policy “Part B” are
reviewed by CBA Blue. See Dental Care in Section 6 for more details.
Pharmacy prior approvals are reviewed by Express Scripts, Inc. (ESI). Note,
however, not all members have pharmacy coverage through BCBSVT.
Refer to our Contact Information for Provider sheet on our provider
website under Pharmacy Benefit Manager for a list of exclusions.
30
Radiology prior approvals are reviewed by AIM Speciality Health.
Refer to the current prior approval listing to determine
what ambulance service(s) require prior approval.
2.Provider has an approved prior approval request on file and
during a procedure provider determines a need for other or
additional services or a change in treatment plan is required.
•This does not include codes left off the prior approval form
inadvertently or given in error. Retrospective review is not considered
in this instance.
We encourage the referring provider obtain the
prior approval for ambulance services.
3.Chiropractic services within three (3) days of visit
following the 12th, 19th, 24th, etc., visits.
Ambulance providers cannot contract with BCBSVT and therefore,
members are financially responsible for the services provided if
prior approval is not obtained. In addition, the referring provider
has the clinical information we need to make a decision.
4.Provider was not aware member had BCBSVT for coverage
or had change in coverage, or Provider received incorrect
information regarding member’s coverage (i.e., eligibility,
benefits or Medicare status), or through eligibility verification
Provider was advised the member was not active.
Special Notes related to Prior Approval
for Ambulance Services
When a rendering provider is requesting a prior approval for
ambulance services, they will need to know the ambulance service
name, location and national provider identifier. No coding is
necessary. BCBSVT uses an ambulance transport service code.
BCBSVT has two business days to review and make decisions on
ambulance prior approval requests, unless they are marked urgent.
Urgent requests have 48 hours to have a decision rendered. If
you do have enough time to file for prior approval before the
transport, you should not mark the request as urgent.
Special Notes related to Prior Approval/
Referral Authorization:
•Home Health Agencies or Visiting Nurse Associations: a new
authorization or an update/extension of an existing authorization does
not need to be submitted or created should a member experience an
inpatient admission during date spans for already approved services.
If the inpatient stay results in the need to adjust the date span of already
approved services, or will result in services spanning a new calendar
year, you need to contact our integrated health management team at
(800) 922-8778. We will adjust the existing authorization accordingly.
Retrospective review of prior approvals,
and referral authorizations
Prior Approval and Referral Authorizations should always be secured
prior to the service (s) being rendered. Providers and facilities are held
financially responsible. There are a few circumstances in which BCBSVT
will complete a retrospective review upon a provider’s request:
1.CPAP/BIPAP/TENS or any other compliance reported durable
medical equipment (DME) within 30 days (30 calendar
days) of the last covered day of the trial authorization.
• If compliance is not received within the 30 days, the entire continuation
will NOT be reviewed.
5.Procedures not appearing on the applicable prior approval or referral
authorization listing, but deny for lack of prior approval/authorization.
6.Provider attempted to obtain prior approval, but was unable due
to, for instance, natural disaster, outages or other extenuating
circumstances that did not allow the provider to reach BCBSVT.
If you have a service that qualifies for retrospective review, you will
need to submit a prior approval form noting it is a retrospective review;
include documentation that (1) supports the procedure provided,
and (2) provide details and supporting documentation of why prior
approval was not originally requested. A review of the case will
be initiated, and you will be advised of the outcome. Please note,
BCBSVT has 30 days to respond to retrospective review requests.
Pre-notification of Admissions
Under the Plan’s certificates of coverage, pre-notification of scheduled
inpatient admission is required. Pre-notification enables the Plan’s
Integrated Health Management staff to assess the medical necessity
of the requested procedure and the appropriateness of the requested
setting of care (inpatient versus outpatient). Clinical information
pertinent to the request is collected as needed. The information is
reviewed in conjunction with nationally recognized health care guidelines
and/or other data sources identified earlier in the description.
If the Integrated Health Management staff cannot certify the
request, the case is referred to a Plan medical director. The Plan
medical director may contact the attending physician or consult
a specialist to address unresolved questions or to discuss other
possible alternatives prior to issuing an adverse determination.
The medical director may approve or deny a service.
31
Written notification of both approval and denial determinations are sent
to the member and treating provider (if known) occurs within 15 days
of request. Copies of the letter are sent to the treating providers, facility
and member. The Plan’s integrated health management department
also keeps a copy as part of the member’s electronic record. In the
case of an adverse determination, the appeal process is outlined in
the letter and is also discussed later in this program description.
Each case reviewed is evaluated for case and/or disease
management. Both integrated health management staff and
physician reviewers participate in a team effort that focuses on the
member’s unique needs. The appropriateness of services, access
to, cost effectiveness and quality of services are all stressed.
The Plan does not retroactively deny reimbursement for
services that received prior approval/pre-notification except
in cases of fraud including material misrepresentation.
See provider contracts for more complete details.
Admission Review
All admissions that require review, but occur without pre-notification,
are considered urgent or emergent and are evaluated within 24 hours
or one business day of notice to the Plan. Admission reviews in this
category are reviewed as noted above. A clinician and medical director
are available to providers (by toll free telephone number) 24 hours a
day, seven days a week, to render utilization review determinations for
urgent or emergent care. Verbal notifications of all urgent and non-urgent
decisions are made within 24 hours to both the member and provider.
Written notifications are issued within 24 hours of verbal notification.
Concurrent Review
Concurrent review applies to inpatient hospitalization or any ongoing
course of treatment. During inpatient hospitalization for circumstances
requiring focused review, the Plan’s clinical reviewers monitor the care
being delivered using Milliman Health Care Guidelines, Current Edition and/
or locally approved health care guidelines. Through telephonic review, the
Plan’s clinician reviews the medical information provided by the facility’s
UR staff while the member is hospitalized. Authorization of continued
hospitalization is based on the medical appropriateness of the care being
delivered and the member’s unique needs. The Plan uses the concurrent
review process to facilitate discharge planning with the treatment team.
If there is a length of stay or level of care issue, it is discussed with
the Plan’s medical director and if necessary, the attending physician
and the hospital utilization review coordinators within 24 hours of
obtaining the necessary medical information. In the event of an adverse
decision, verbal notification is provided to the member and treating
provider (if known), and a written notification is sent, within 24 hours
of the verbal notification, to the member and the provider(s).
32
During the concurrent review process, if the integrated health
management staff identifies a quality of care issue, the case is
referred to the QI department or the credentialing committee for
investigation. The BCBSVT QI department or credentialing committee
will use the BCBSVT Quality Improvement Policy, Quality of Care and
Risk Investigations Policy to complete the investigation. The policy
is located on the secure provider portal at www.bcbsvt.com
under BCBSVT Policies then the Quality Improvement link. Or, you
can call your provider relations consultant for a paper copy.
The Plan does not retroactively deny reimbursement for
services that received prior approval/pre-notification except
in cases of fraud, including material misrepresentation.
See provider contracts for more complete details.
Discharge Planning and Discharge Outreach
Discharge planning occurs during the inpatient concurrent review process.
During the concurrent review process, the Plan’s clinician case manager
works collaboratively with the caregivers to facilitate appropriate and
timely services. The extent of the clinician’s direct role in planning and
arranging post-discharge care varies with the patient needs and includes
a collaborative approach with the hospital staff, care team, patient/family
and community resources representatives as appropriate. Upon discharge,
each member is contacted by the discharge outreach coordinator, a
clinician, who reviews the member’s discharge plan and assists with
coordination of services as needed. During the outreach, the clinician will
assess the need for referral to case management, disease management or
behavioral health management and will facilitate said referral if applicable.
Urgent Pre-Service Review
Urgent pre-service review applies to any request in which the
member’s health could be compromised by delay. Expedited decisions
are reached and providers are notified within 72 hours of the
request. Verbal notification is provided to the member and
treating provider (if known) with written confirmation of
the decision within 24 hours of telephone notification.
Case Management
Blue Cross and Blue Shield of Vermont adopted the Case Management
Society of America’s case management definition: Standards
of Practice for Case Management revised 2010.
“Case management is a collaborative process of assessment,
planning, facilitation and advocacy for options and services to
meet an individual’s health needs through communication and
available resources to promote quality cost-effective outcomes.”
The specialty case management program is a member-centered,
proactive program designed to identify the at-risk members as early
as possible. The program works collaboratively with our disease
management, behavioral health, dental, and pharmacy partners, and is
focused on chronic diseases that are typically high-cost and are potentially
actionable with appropriate intervention and lifestyle changes. The clinical
case manager applies the four primary functions of case management:
advocacy, assessment, planning and facilitation, to identify barriers to the
member attaining appropriate, timely and quality care. The program is an
organized effort to identify potentially high cost/high risk members with
complex health needs, as early as possible, assess alternative treatment
options, assist in stabilizing or improving member’s health care outcomes
and manage health care benefits in the most cost effective manner.
The managed diagnostic categories and focus populations include
diabetes, general, HIV/AIDS, acute and chronic neurology, progressive
degenerative disorders, end of life/palliative care, high-risk obstetrics,
pediatrics, transplant and oncology with or without metastasis.
Provider Referrals to Case or Disease Management
Providers are encouraged to refer BCBSVT/TVHP members
directly into our case or disease management programs by calling
(800) 922‑8778, option 1. Our intake triage staff will record the
information and complete outreach to the member for enrollment.
Rare Condition Program (BCBSVT partnership
with Accordant Health Services)
The BCBSVT Rare Condition Program can help your patients improve
their conditions, enhance their knowledge and self-management
skills and achieve your therapeutic goals for them. Full details are
available in our online brochure located on the provider website
under Provider Manual/Reference Guides/General/Accordant.
The Plan annually assesses the characteristics and needs of
its member population and relevant subpopulations and
reviews and updates the case management process and case
management resources to address member needs if necessary.
If it is determined that the member has the potential to benefit from case
management, a welcome packet is sent defining case management’s
role and the member’s rights and responsibilities in participation.
Once the member consents to participate in and collaborate with the case
manager, a comprehensive assessment is completed with the member
who is considered to be an active participant on the interdisciplinary
team and the health care team. In collaboration with the member,
case manager and provider, a member-specific case management
plan of care is developed to support the member’s clinical plan of care,
which includes both short and long term, prioritized goals, nursing
interventions, a member self-management plan and discharge criteria.
Case management services may be terminated once the goals are met
and the member no longer requires case management services or, since
the program is voluntary, the member requests termination of services.
Case management services can be reinstated at any time. All information
regarding the member is considered confidential and is not shared with
anyone who is not part of the interdisciplinary team without written
consent of the member or person with medical power of attorney.
Episodic Case Management/Authorization of Services
Episodic case management/authorization of services targets individuals who
have short-term intervention needs, usually for a period of six to 12 weeks or
for a specific illness episode. This applies also for members who demonstrate
evidence that their needs are being met by support groups or other community
agencies and whose only needs are to have services authorized. The value
of this program is to expedite care from hospital to home or an alternative
setting and to promote continuity of service across the continuum.
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Section 5
Quality Improvement (QI) Program
Clinical Guidelines: The Plan develops or adopts clinical
guidelines that are relevant to its clinical quality improvement
goals. The Plan reviews and, as appropriate, updates its clinical
guidelines a minimum of every two years, and distributes the
guidelines to providers within the relevant practice area.
Blue Cross and Blue Shield of Vermont and The Vermont Health
Plan’s Quality Improvement Program provides the framework
by which the organizations assess and improve the quality of
clinical care and the quality of service provided to our members.
Both organizations are referred to here as “the Plan.”To receive
a copy of the Plan’s Quality Improvement Program Description,
contact the Director of Quality Improvement at (802) 371-3230.
Medical Record Reviews & Treatment Record Reviews: The
BCBSVT Quality Improvement Policy, Medical Record Review &
Treatment Record Review provides the complete details of the
definitions, review procedure performance improvement plans,
reporting. The policy is located on the secure provider portal at
www.bcbsvt.com under BCBSVT Policies then the Quality Improvement
link. Or, you can call your provider consultant for a paper copy.
The Plan QI program identifies the leading health issues for our
members, areas where current treatment practice runs counter to
established clinical guidelines and, by working with both members and
providers, takes action to modify or improve current treatment practice.
In addition, the program assesses the level of service the Plan and our
networks provide to our members and by working with members and
providers, takes action to improve service. Input from both providers
and members is essential to meeting the goals of our program.
Member Satisfaction Surveys: The Plan surveys members who have
sought services from primary care or OB-GYN physicians to assess their
satisfaction with these network physicians. Periodically, the Plan shares
results of member satisfaction surveys with physicians. In cases where
member satisfaction is not consistent with the Plan’s standards, the
Plan takes appropriate action to correct deficiencies, monitors provider
performance against corrective actions and takes appropriate and
significant action when a provider does not follow through on
corrective action.
Some of the Plan’s quality improvement initiatives that affect
providers are outlined below. The Plan reserves the right to
develop and implement other quality improvement initiatives
that may require provider involvement or cooperation.
Quality Improvement Projects: As part of their participation in
managed care products, the Plan expects its provider network to
contribute to the success of the Plan’s quality improvement projects.
The projects define a measurable goal around a specific clinical issue
in a particular population, identify barriers that contribute to gaps in
care, implement member and provider interventions to address the
issue, measure the success of the project and then reassess barriers and
interventions. Through FinePoints, a newsletter to the provider community,
and other notifications, the Plan alerts its provider network about its
quality improvement projects and the role of providers. The Plan expects
providers to participate in the quality improvement project, encourages
members to participate and provides feedback on the project.
Quality Profiles: Each year, the Plan compares practice patterns
in Vermont to nationally recognized guidelines. The results are
reported to physicians so they may evaluate their practice patterns
in relation to national guidelines and their peers. In cases where
practice patterns seem inconsistent with national guidelines and
the Plan’s standards, the Plan takes appropriate action to correct
deficiencies, monitors provider performance against corrective
actions and takes appropriate and significant action when a
provider does not follow through on corrective action.
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Member Complaints: The Plan documents and tracks member
complaints and may, as appropriate, share results with network
providers. In circumstances where member complaints focus
attention on a specific concern about a provider, the Plan may
share the feedback with the provider, engage the provider in
developing corrective action, monitor the provider’s performance
against corrective action and take appropriate and significant action
when a provider does not follow through on corrective action.
HEDIS and Quality Data Gathering: On an annual basis, the Plan
participates in the HEDIS (Health Plan Employer Data and Information
Set) survey and, at the same time, gathers data to support its quality
improvement projects. HEDIS is the most widely used set of performance
measures in the managed care industry and provides important
information about how the Plan compares to other plans in terms of
quality indicators. The Plan’s participation is required by the State of
Vermont and is critical to the improvement of the clinical quality for
its members.
Standards of Care: Each year, the Plan develops or adopts standards
of care relevant to the health needs of the Plan’s membership. The Plan
distributes guidelines to its networks and measures guideline compliance.
The Plan updates the guidelines at least every two years. The Plan has
adopted clinical practice guidelines in the following areas: asthma,
hypertension, diabetes, smoking cessation, obesity, obstructive sleep
apnea, depression, preventive health, adult migraine headaches, antidepressant medication follow-up, colonoscopy and acute pharyngitis.
Provider Feedback: Developing and maintaining a preferred partner
relationship with the provider community is one of our goals as a
company and a focus of our quality improvement program. There are
many ways that providers can let us know how we’re doing:
•Contact a provider relations representative at (888) 449-0443.
•Provider complaints—call our Customer Service department
at (800) 924-3494. The Plan logs and reports on complaints
regularly to note trends and areas of particular concern.
•Provider Satisfaction Surveys—conducted annually and mailed
to every provider in our network. Look for yours every fall.
•Participation in quality improvement committees is outlined below.
Quality Improvement Committees
The Plan maintains several quality improvement committees that
provide an opportunity for network physicians to participate actively in
developing and overseeing the Plan’s quality improvement program.
The Plan invites providers to contact the quality improvement department
at (802) 371-3230 if they would like to participate in a quality committee.
Quality Oversight Committee: This committee provides oversight of
the quality improvement program. It reviews HEDIS and CAHPS data and
other quality indicators, identifies and prioritizes quality improvement
opportunities, develops and oversees quality improvement projects and
other quality activities and serves as liaison for the Plan’s quality program
and the provider network. The committee meets six times a year.
Quality Improvement Project Teams: Through quality improvement
projects, the Plan seeks to improve the care and service its members
receive, both from the Plan and its networks. The projects are carried out
through the work of a team made up of clinical and non-clinical staff.
The Plan invites its network providers to propose quality improvement
projects or to serve as clinical advisors on quality projects.
Credentialing Committee: The Plan’s credentialing committee
reviews the qualifications and background of providers applying or
reapplying for networks participating with the Plan. In addition, the
Plan’s credentialing committee reviews quality issues that may arise
with a particular provider and makes appropriate recommendations.
Specialty Advisory Committee (SAC):The Plan convenes Specialty Advisory
Committees as necessary to review clinical guidelines on particular topics and
assists in tailoring the guidelines for more effective use inVermont. Examples of
past SAC topics include cardiology, orthopedics, oncology and OB-GYN.The Plan
encourages network providers to propose SAC topics or to volunteer for a SAC.
BCBSVT/TVHP Special Health Programs
Better Beginnings
Better Beginnings® is a voluntary and comprehensive prenatal program.
The program identifies early in their pregnancies those women who
may be at risk for pregnancy complications. It encourages early prenatal
care and collaboration between the member and her provider to reduce
complications and the potential associated high costs. Better Beginnings
provides benefits tailored to individual needs that may help to reduce
risk factors that can trigger pre-term labor and/or other complications.
All BCBSVT members are eligible for the program, with the exception
of the Federal Employee and New England Health Plan programs.
An expectant mother can enroll at any time during her pregnancy, but
BCBSVT must receive enrollment paper work prior to delivery. It is ideal if
member enrolls as early as possible in her pregnancy. There is a reduction
in benefits if a member enrolls after 34 weeks gestation. Please refer
expectant mother to the website: www.bcbsvt.com/member/Health_
and_Wellness/betterbeginnings.html on information on how to register.
Upon receipt of the completed paperwork a BCBSVT registered nurse
case manager will contact the expectant mother to inquire about the
progress of her pregnancy and to discuss any possible risks the HRA
revealed. We send educational materials on pregnancy and childbirth to
the expectant mother. The same RN case manager will follow the member
through her pregnancy and in the postpartum period. The nurse may offer
case management if the expectant mother is at high risk for complications.
If you would like more information on the Better Beginnings®
Program, or would like to refer a patient, please call
(800) 922-8778, select option 1. Members may also call our
Customer Service department at (800) 247‑2583 for more
information about the Better Beginnings® Program.
Brochures for this program are available free of charge. These brochures can
be placed in your waiting areas, or you may include them in patient care
kits. To order a supply, simply contact your provider relations representative
at (888) 449-0443 and request Better Beginnings® Program brochures.
Diabetes Education/Training
BCBSVT/TVHP provides a benefit for outpatient diabetes self-management
education/training services and related durable medical equipment and
supplies for eligible members. This benefit is provided so that our diabetic
members can learn strategies to effectively manage their diabetes and
to avoid complications often associated with this chronic disease.
Providers of outpatient diabetes educational/training services must
participate with the Plan and meet the Plan’s credentialing criteria for diabetes
education in order to be eligible for reimbursement. Eligible providers
must submit a separate credentialing application, specific to diabetes
35
education, to BCBSVT/TVHP. The credentialing procedures are similar to those
outlined in section one, but the Plan also requests information on providers’
certification and training in the education and management of diabetes.
Benefits are available for diabetes self-management eduction/training
services for eligible members if all of the following criteria is met:
•The member has one of the following diagnosis:
•Insulin dependent diabetes
•Gestational diabetes
•Non-insulin dependent diabetes
•The member is capable of self-management, including self-administration
of insulin (or in the case of children, parental management)
•A qualified outpatient diabetes education/training
education program that participates with the Plan.
If a member has a chronic or serious condition, they can get phone
support, information by mail and videotapes on a range of diagnoses
and treatment options from our clinicians. If a member need answers
to everyday problems, our clinicians provide easy access at any
time of the day or night by phone or via the web. Members can call
toll-free (866) 612-0285 to speak with one of our clinicians.
In addition to health management and support programs,
BCBSVT has a host of fun, effective programs designed to
reward our members for healthy behavior. Among them:
Hospice
•WalkingWorks, a program that makes it easy and fun to
keep track of the success at walking for fitness
•BlueExtras, a program that provides discounts on weight loss
programs, hearing aids and a host of local goods and services
•EatSmart Vermont, a program that encourages restaurants
to offer and promote healthy choices on their menus
The hospice program offers eligible patients who are terminally
ill and their families an alternative to hospital confinement.
The attending physician, in collaboration with a participating home
health agency, prepares a comprehensive home care treatment plan
in order to assure the member’s comfort and relief from pain.
At BCBSVT, our goal is to ensure that all our members get the care and
support they need, regardless of their health care status. Our full spectrum
of Blue HealthSolutions programs allows us to maximize each member’s
chance at getting and staying healthier. By using Blue HealthSolutions, our
members make the best use of the dollars they spend on health benefits.
Benefits:
We cover the following services, by a Hospice
Provider and included in the bill:
•skilled nursing visits;
•home health aide services for personal care services;
•homemaker services for house cleaning, cooking, etc;
•continuous care in the home;
•respite care services;
•social work visits before the patient’s death
•bereavement visits and counseling for family members up to one year
following the patient’s death;
•and other Medically Necessary services.
Provider Selection Standards
Requirements:
We only provide benefits if:
•the patient and the Provider consent to the Hospice care plan; and a
primary caregiver (family member or friend) will be in the home.
BlueHealth Solutions
The Blue HealthSolutions information and support program helps
our members learn about the care they’re getting. The various
components of the program (a 24-hour phone-in nursing support
line, an advertising-free website and a self-help book among them)
help our members to learn about all the options ­available.
36
To participate in the BCBSVT or TVHP’s networks, a provider must
1. Be licensed in a discipline that has consistent requirements and
training programs (the Plan specifically excludes certain licensed
providers, including but not limited to professional nurse midwives,
massage therapists, and acupuncturists)
2. Meet initial credentialing criteria as outlined in the Initial Credentialing
Policies available upon request from your provider relations consultant
3. Agree to a recredentialing review every three years as outlined in the
Recredentialing Policies
4. Provide a complete application including an attestation of
•Ability to perform the essential functions of the position
•Lack of illegal drug use at present
•History of loss of license and/or felony convictions
•History of loss or limitation of privileges or disciplinary action
•Accuracy and completeness of information
5. Agree to the Plan’s access and appointment availability standards as
specified in Vermont Rule 10
6. Agree to provide 24-hour coverage (primary care providers only)
7. Practice in the state of Vermont or in a state with a contiguous border
with Vermont (except Durable Medical Equipment suppliers or
Lab Services
8. Agree to BCBSVT and/or TVHP payment rates
9. Agree to sign a contract with BCBSVT and/or TVHP and adhere to the
contractual provisions.
Provider Appeal Rights
The Plan may deny a provider’s participation in its networks for
reasons related to credentialing criteria, quality or performance.
Physicians or providers who are notified of a denial are entitled
to a statement of the reasons for the denial. A provider wishing
to appeal a removal from the network or entry into the network
may be entitled to a hearing as outlined in the policy entitled
Investigation and Resolution of Quality of Care Issues and Appeals
available upon request from your provider relations representative.
Credentialing verification is required for all lines of business
to review the background and performance of physicians/
providers and to determine their eligibility to participate
in the network. Credentials such as current license, license
history, specialty, Drug Enforcement Agency (DEA) Certificate,
malpractice history and education are verified when a provider
enters into the network and again every three years.
Blue Cross and Blue Shield of Vermont and The Vermont Health Plan
delegates a portion of its network credentialing to Physician Hospital
Organizations (PHOs). The Plan monitors these delegates’ credentialing
procedures and assures compliance with Plan standards as well
as the standards of the National Committee for Quality Assurance
(NCQA) and the Department of Financial Regulation (DOFR).
Recredentialing Procedures
The Plan recredentials all network providers and facilities every
three years. Providers and facilities must return a completed
recredentialing application. The Plan will conduct primary source
verification and a performance appraisal for the credentialing
committee’s review. Performance appraisal elements include
•Member complaints
•Member satisfaction surveys
•Quality Improvement profiles
•Quality reviews (site visits and medical record reviews)
•Utilization management review
Confidentiality
Credentialing information obtained in the credentialing process is kept in
a locked/secured area. All Plan employees sign a confidentiality statement
as a condition of employment. All materials and processes are subject to
the standards outlined in the Plan’s Confidentiality and Security Policy
available upon request. All credentialing information shall be retained for a
minimum of two credentialing cycles or for six years, whichever is longer.
The minutes and records of the credentialing committee are
confidential and privileged under 26 V.S.A. §1443, except as otherwise
provided in 18 V.S.A. §1914(f)(2) and Vermont Rule 10.306(B).
Providers may request copy of the Plan’s Credentialing Policy from
our Provider Relations Department by calling (888) 449-0443
Medical and Treatment Record Standards
Medical Record Review
The Plan requires all providers to maintain member records in a
manner that is current, detailed and organized permitting effective
member care and quality review. Records may be written or
electronic. The Plan conducts a medical record review of its highvolume primary care providers and a treatment record review of its
high-volume mental health and substance abuse providers at least
every three years and checks for critical elements, general elements
and confidentiality and organized records keeping policies. The
Plan does not need to include Blueprint practices using electronic
records as the state deems them compliant with this requirement.
Provider records must reflect 100 percent compliance with critical
elements and confidentiality and organized record keeping policies,
and 80 percent compliance with the general elements to pass the
review. The Plan reserves the right to extend this records review
to any provider of any specialty at any time and apply the same
standards. The Plan requires performance improvement plans from
providers who do not pass the medical record review or treatment
record review and conducts a repeat review in approximately six
months time. The Plan will maintain all results and correspondence
relating to record review in the secure credentialing database. The
Plan may use these results to make future credentialing decisions.
The complete Medical Record Review & Treatment Record Review policy
is available on our secure website. We would encourage you to review
for the full details. If you encounter any issues or are unable to access the
web, please contact your provider relations consultant at (888)449-0443.
Retrieval and Retention of Member Medical Records
•Members must have access to their medical records during business
hours for a charge not to exceed copying costs.
•The Plan will have access to member medical records, during regular
business hours, to conduct quality improvement activities.
•Providers retain records as per individual practice policies in accordance
with all state and federal laws.
Office Site Review
The BCBSVT Quality Improvement Policy, Site Visit and Medical Record
Keeping Policy provides the complete details of the requirements. The
policy is located on the secure provider portal at www.bcbsvt.com under
37
BCBSVT Policies then the Quality Improvement link. Or, you can
call your provider relations consultant for a paper copy..
38
Section 6
General Claim Information
Our mission is to process claims promptly and accurately. We generally
issue reimbursements on claims within 45 calendar days.
Industry Standard Codes
Providers can submit claims electronically using an 837 A1 HIPAA
transaction set or on paper using the standard CMS 1500 claim form.
timely filing and cannot be billed or collected from the Member. A Provider
may request a review of denials based on untimely filing by contacting
our Customer Service Department or submitting a Provider Inquiry Form
within ninety (90) days of the Remittance Advice denial. The Provider
Inquiry Form must include supporting documentation such as original
claim number, copy of an EDI vendor report indicating that the claim was
accepted for processing by BCBSVT within the filing limit, or a copy of the
computerized printout of the patient account ledger with the submission
date circled. Requests for review of untimely filing denials will be reviewed
on a case by case basis. If the denial is upheld, a letter will be generated
advising the provider of the outcome. If the denial is reversed, the claim
will be processed for consideration on a future Remittance Advice.
Services must be reported using the industry standard coding of
Current Procedural Terminology (CPT) and / or Health Care Procedure
Coding Systems (HCPCS). To align with the industry, on a quarterly basis
(January, April, July and October) BCBSVT also updates the CPT and HCPCS
codes. We complete a review of the new/revised/deleted codes post a
notice to the news area of our provider website a
www.bcbsvt.com advising of any changes in prior approval
requirements, changes in unit designation, and any other information
you should be aware of specific to the new/revised/deleted codes. The
posting appears no later than at least two weeks prior to the effective date.
Adjustments—Must be submitted no more than 180 days
from the date of BCBSVT or TVHP original payment or denial.
Diagnoses must be reported using Internal Classification of Disease,
9th revision, Clinical Modification (ICD-9-CM) and the DSM-III
R, Codes that can be taken out to a fifth digit, must be reported
to the fifth digit. The Plan begins using the newest release of
ICD-9-CM and DSM-III R codes in October of each year.
Individual members enrolled through the State’s Health
Exchange have very specific grace periods.
Balance Billing Reminders
Covered Services—Participating and network providers accept
the fees specified in their contracts with BCBSVT and TVHP as
payment in full for covered services. Providers will not bill members,
except for applicable co-payments, coinsurance or deductibles.
Non-Covered Services— In certain circumstances, a provider may
bill the member for non-covered services, please refer to Section
1 – Billing of Members and Non-Covered Services for more detail.
Reimbursement—Payments for BCBSVT and TVHP are limited
to the amount specified in the provider’s contract with BCBSVT
and/or TVHP, less any co-payments, coinsurance or deductibles
in accordance with the member’s benefit program.
Claim Filing Limits
New Claims—New Claims must be submitted no more than one
hundred eighty (180) days from the date of service or in the case of a
coordination of benefit situation, one hundred eighty (180) days from
the date of the primary carrier’s payment. Claims submitted after the
expiration of the one hundred eighty (180) day period will be denied for
Claim submission when contracting with more than one Blue
Plan: Providers who render services in contiguous counties or have
secondary locations outside the State of Vermont may not always
submit directly to BCBSVT. We have created three guides to assist
which are located on our provider website at www.bcbsvt.com.
Grace Period for Individuals through the Exchange
The federal Affordable Care Act requires that individuals receiving
an advanced premium tax credit for the purchase of their health
insurance be granted a three month grace period for nonpayment of premium before their membership is terminated.
BCBSVT administers the grace period as follows:
Claims for dates of service during the
first month of grace period:
We process the claims, make applicable payments and reports through
to a remittance advice. Those payments are never recovered even if
the membership terminates at the end of the grace period. If you
find at a later date (and within 180 days of original processing) that
you need to request an adjustment on one of these claims, simply
submit following our standard guidelines and the adjustment will
process through as usual. If additional money is due, it will be paid.
Claims for dates of service during the second and third
month of the grace period:
Claims are suspended. We alert you that the claim is
suspended by letter sent through the US postal service to
39
the address you have on file as a payment address.
•If the premium is paid in full* at any point during month two or
three, the claim(s) is released for processing and reported through
to a remittance advice paying any applicable amounts.
•If the premium is not paid in full prior to the end of the three
month grace period, the suspended claim(s) is denied through to a
remittance advice and reports as membership not on file reflecting
the full billed amount as the member’s liability. The member also
receives an explanation of benefits with this information.
•Per the Affordable Care Act, when a member is within a grace
period, they must pay all amounts due, up through their
current billing period to keep their insurance active.
errors, (3) bcbsvt observation services payment policy, and
(4) BCBSVT provider based billing payment policy.
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or
CMS 1500 types) for claims that are in month 2 or 3 of their grace
period cannot be processed. They should not be submitted to BCBSVT
until after the claim has processed and reported to a remittance
advice. If you do happen to submit a correct claim or adjustment
it will be returned directly to your office advising the member is
within their grace periods and the correct claim or adjustment can
be submitted after payment is made or termination is complete.
Change Healthcare (formerly known as EquiClaim) performs
quality assurance review of claim processing for:
•Facility billing (including DRG reimbursements)
•High cost injectable drugs
•Home infusion
•Renal dialysis
Take Back of Claim Payments & Overpayment
Adjustment Procedures
It is BCBSVT’s and TVHP’s policy to collect any
overpayments made to the provider in error .
When membership is terminated retroactively, BCBSVT and TVHP
recover payments made for services provided after the termination
date. Providers should then bill the member directly. Individuals who
are covered through the Exchange have separate guidelines. For full
details see “grace period for individuals through the exchange”.
If we learn of other insurance or other party liability, BCBSVT
and TVHP recover payments made for services.
BCBSVT partners with Cotiviti Healthcare to provide
reviews on coordination of benefit (COB) claims.
Cotiviti Healthcare looks at the following COB concepts:
•Active/Inactive
•Automatic Newborn Coverage
•Birthday Rule
•Dependent/Non dependent
•Divorce Decree
•Longer/Shorter
•Medicare Age: Entitlement, Disability Entitlement, Crossover, Domestic
Partner, ESRD Entitlement, Home Health, Part B only
Cotiviti also performs claim reviews for (1) duplicate services,
(2) claims suspected to have administrative billing and payment
40
Most of the reviews are performed without any additional
information from providers. They rely on the information
contained on the claim(s), attachment(s) or information BCBSVT
has already collected during the initial COB process.
Cotiviti Healthcare may need to outreach to your office directly to obtain
more information. Please be advised that we do have a signed business
associate agreement with Cotiviti Healthcare. You can release the
requested information to them directly. Please make sure you do respond
within the time frame that is specified in the Cotiviti Healthcare request.
If you receive a request for information from Change
Healthcare (or EquiClaim, as they still use that name at
times) please make sure to respond promptly.
When you detect an overpayment, please do not refund the overpayments
to BCBSVT/TVHP or the patient. Instead, please complete a Provider
Overpayment form. For an accurate adjustment, it is important to
include all the information requested on the form. We will adjust the
incorrectly processed claim by deducting from future payments.
We prefer to recover, rather than accept funds from you, because
•Claims history will simultaneously be corrected to
accurately reflect the service and payment,
•The remittance advice will reflect correction of the original claim, and
•Providers do not incur the expense of sending a check.
The Provider Overpayment form is available on the
www.bcbsvt.com provider web site.
Accounting for Negative Balances
When the Plan needs to correct an overpayment on a claim,
the amount of the incorrect payment is automatically
deducted from future payments to the provider.
The overpayment adjustment will report as a negative on the
providers Remittance Advice. The amount due will be subtracted
from the total payment for the Remit. When the amount of the
overpayment adjustment is larger than the total amount due or when
the overpayment adjustment is the only line item on the Remittance
Advise, a negative balance is created. The negative balance will
report through to every Remit until the balance is cleared up.
Do not issue checks to the Plan for the amount the report shows as a
negative. Typically, negative balances are resolved with the next Remit
and refunding the money would only result in a provider overpayment.
Please note: Negative balances do not cross product lines. For
example, if you have a negative balance on a BlueCard remittance
advice, the outstanding negative balance would not be taken
on your indemnity, TVHP or FEP remits. It would continue
to be taken on your next BlueCard remittance advice.
Where to Find Co-payment Information
A co-payment is an amount that must be paid by the member for
certain covered services. This amount is charged when services
are rendered. The amount of co-payment can be obtained by:
•Checking the front of the member’s identification card,
•Using the secure website at www.bcbsvt.com
(see Section Two of this manual for details), or
•PCPs can refer to the monthly membership reports.
Co-payments and HealthCare Debit Cards
Some members, to cover out-of-pocket costs, use HealthCare Debit Cards.
Out-of-Pocket expenses are co-payments, deductibles and/or coinsurance
amounts that are not paid by the member’s health plan. Debit cards
typically have a major debit card logo such as MasterCard® or Visa®.
Some BlueCard members have a Blue Cross and/or Blue Shield healthcare
debit card – a card with the nationally recognized Blue Cross and/
or Blue Shield logos, along with the logo from a major debit card.
The debit card should only be used to collect co-payments
or to pay outstanding balances on billing statements
(after BCBSVT has processed the claim).
If a member arrives for an appointment and presents a debit card,
you may charge the co-payment amount to the debit card. Please be
sure to verify the co-payment amount before processing payment.
The card should not be used to process the full charges up front.
Submit the member’s claim to BCBSVT.
Your Remittance Advice will provide you with the results of claims
processing and reflect any balances due from the member. The member
may choose to pay any balances due with the debit card. In that case, the
member would bring the card to your office and authorize the payment.
How to use a Healthcare Debit Card
The cards include a magnetic strip so if your office currently
accepts credit card payments, you can swipe the card at the
point of service to collect the member’s payment.
Select “credit” when running the card through for payment.
No PIN is required.
The funds will be sent to you, and will be deducted automatically
from the member’s appropriate HRA, HSA or FSA account.
Waiver of Co-payment or Deductible
There may be situations where a provider does not want to collect a
co-payment (or deductible) from a member, or where the provider wishes
to collect a lesser amount than that which is due under the terms of a
member’s benefit program. The circumstances under which a provider
may waive all or a portion of a co-payment or deductible due from a
member are limited, however. A provider may not waive a member’s
co-payment or deductible in an attempt to advertise or attract a member
to that provider’s practice. A provider should limit waiver of co-payments
or deductible to situations where (1) the provider has a patient financial
hardship policy (sometimes called a sliding-scale) and (2) the member
in question meets the criteria for reduced or waived payment.
When to Collect a Co‑payment
High Dollar Imaging
When a member has a co-payment for high dollar imaging, the
co-payment amount is only taken on the facility claim. The
professional (reading) claim will not apply a co-payment.
For plans with a co-payment and then deductible, the facility
claim will take the co-payment and any applicable deductible. The
professional (reading) claim will only take applicable deductible.
Please note: Administrative Services Only (ASO) groups may have
different applications of co-payments for high dollar imaging.
Mental Health and Substance Abuse
BCBSVT members have access to certain mental health and substance
abuse services for the same co-payment as their primary care
provider visit. A list of these services are available on our provider
website at www.bcbsvt.com under policies, provider manual &
reference guides, mental health and substance abuse co-payment.
41
Physician’s Office
A co-payment is collected when an office visit service is rendered.
Generally, co-payments are applied to the Evaluation and Management
(E & M) services, which include office visits and exams performed in
the physician’s office. BCBSVT and TVHP’s reimbursement excludes
the co‑payment that the physician collects from the member.
If a member has two BCBSVT policies, the member is responsible
for one co-payment; the policy with the lowest co-payment for
the service will apply the co-payment. For example, if the primary
BCBSVT policy has an office visit co-payment for $20 and the
secondary BCBSVT policy has an office visit co-payment of $10,
the member will only be responsible for a $10 co-payment.
Grandfathered Benefits Rider
2010 Benefit Changes Rider - GF
Direct Pay 2010 Benefit Changes Rider - GF
If a rider appears titled Preventive Care Rider, the preventive
benefit follows the federal and includes women’s health.
Member Responsibility for Co-payment
Members are expected to pay co-payments at the time service is provided.
Claims Status, Returned Claims,
Resubmission and Denied Claims Process
Preventive Care:
Electronic Data Interchange (EDI) Claims
BCBSVT/TVHP members have preventive benefits that either follow the
federal guidelines of the Affordable Care Act (ACA) or are part of their
“grandfathered” employer benefit and do not take a co-payment.
Submitting claims via EDI has many advantages:
•Reduced paperwork
•Savings on postage costs
•Immediate feedback on potential claim problems that affect payment
•Reduced processing time
Grandfathered preventive care follows the
traditional BCBSVT preventive guidelines.
Groups with the federal preventive benefit also include benefits
for women’s health services with no additional co-payment. We
have posted a brochure for the federal preventive benefits to the
references area of our provider website. This brochure provides
the details on the qualifying Current Procedural Terminology or
Health Care Procedure Coding System and diagnosis codes.
To determine is a member has a “gandfathered” employer benefit
or federal benefit verify a member’s eligibility by logging into our
secure provider website eligibility tool at www.bcbsvt.com or
call our customer service department at (800) 924-3494. Business
hours are Monday through Friday, 7 a.m. - 6 p.m.
When verifying the member eligibility through the secure
provider portal, scroll down to the bottom of the section “Benefit
Plan Information”. Click on the “ADDITIONAL RIDERS” link.
We encourage providers to submit claims electronically.
Electronic Billing Specifications are available on the bcbsvt.com
website or if you have questions about electronic claims, please
call Electronic Data Interchange (EDI) support at (800) 3343441, option 2, or e-mail us at [email protected].
General EDI Claim Submission Information
BCBSVT and TVHP use several clearinghouses to accept claims.
All transactions received need to be in an 837 HIPAA compliant
format. To obtain a listing of clearinghouses please contact
EDI Technical Support at (800) 334-3441, option 2.
Paper Claim Submission
Claims not submitted electronically must be
submitted on an CMS 1500 claim form.
How to Avoid Paper Claim Processing Delays
If one of the following riders appears after clicking on the
link, the preventive benefits are grandfathered:
42
Please avoid the following to promote faster claim processing:
•Missing or invalid information
•Hand written claim forms
•Claim forms that are too light or too dark
•Poor alignment of data on the form
•Forms printed in non-black ink
Attachments
Attachments typically slow down the claim payment
process and most are not needed for claim processing. Do
not attach the following information to a paper claim:
•Medical documentation, unless instructed to do so
•Tax ID and address changes (See section One for full instructions)
The following information must be attached to the applicable claims:
•Coordination of benefits (COB) information
(primary carrier explanation of benefits)
•Descriptions for the following codes: NEC (not elsewhere classified), NOS
(not otherwise specified) along with applicable and/or operative notes.
•Modifiers requiring documentation (such as modifier
22, refer to section 6 for full details)
Coordination of Benefits (COB)
COB is the process that determines which health care plan pays for services
first when a patient is covered by more than one health care plan.
The primary health care plan is responsible for paying the
benefit amount allowed by the member’s contract.
The secondary insurer is responsible for paying any part
of the benefit not covered by the primary plan (as long
as the benefit is covered by the secondary plan).
In most cases, the total paid by both plans may provide
payment up to, but not exceeding, BCBSVT and TVHP’s
allowed price. For BlueCard claims, refer to Section 7.
If COB applies, the primary carrier’s Explanation of Benefits
(EOB) must be attached to the claim and the following
areas of the CMS 1500 must be completed:
•Box 9: Other insured’s name
•Box 9a-d: Other insured’s policy or group number
•Box 11d: Marked “yes”—unless Medicare or Medicaid
is the primary insurer, then mark the “no”
•Box 29: Amount paid
Note: For BCBSVT members, injuries which are work related, are an
exclusion of our certificates. BCBSVT does not coordinate with workers
compensation carriers or consider balances after workers compensation
makes payment. We do however, allow consideration of services where
worker’s compensation has denied the claim as not work related.
Medicare Supplemental and Secondary Claim Submission
BCBSVT participates in the Coordination of Benefits Agreement
(COBA) Program with the Centers for Medicare and Medicaid
Services (CMS). This means that the majority of paper
submissions for these types of claims are not required.
At this time claims for Federal Employees (those with an alpha
prefix of “R”) and claims that qualify as a “mass adjustments” do
not crossover. This means that Medicare crossover claims that are
for FEP members or mass adjustments will have to be submitted
by the provider or billing service after Medicare has processed the
claim. The original claim and a copy of the Explanation of Medicare
Benefits (EOMB) will have to be submitted on paper to BCBSVT.
How COBA works: In order for crossover to occur, BCBSVT provides the
Medicare Intermediary with a membership file so that the intermediary
can recognize BCBSVT as a secondary or supplemental insurer for the
member. The actual crossover occurs when the intermediary has matched
a claim with a BCBSVT member. Once the claim is matched to the
BCBSVT membership file, the intermediary forwards that claim to BCBSVT
and sends an explanation of payment to the provider. The explanation
of payment will indicate that the claim has been forwarded to a
supplemental insurer. Once BCBSVT receives the claim, it will process the
claim according to the member’s benefits and the provider contract and
generate a remittance advice to the provider. If the Medicare Intermediary
is unable to match a member’s claim to a supplemental insurer’s
membership file, the explanation of payment forwarded to the provider
will indicate that the claim has not been forwarded a supplemental
insurer. In this case, the provider should submit the claim on paper to
BCBSVT and include the Explanation of Medicare Benefits (EOMB).
Quick Tips:
•When Medicare is primary, submit claims to your local
Medicare Intermediary. After receipt of the explanation
of payment from Medicare, review the indicators.
•If the indicator on the RA shows the claim was crossed-over,
Medicare has submitted the claim to BCBSVT and the claim is in progress.
•If there is no crossover indicator on the explanation of benefits,
submit the claim BCBSVT with Medicare’s EOMB.
•If you have any questions regarding the crossover indicator, contact the
Medicare Intermediary directly.
•Please note that all paper claims are reviewed and if the Medical EOMB
has not exceeded the 30-day mark, the complete claim will be returned
requesting that it be resubmitted at the 30-day mark.
•Do not submit Medicare-related claims to BCBSVT before receiving
a RA from Medicare. The one exception is statutorily excluded services
or providers. Those can be submitted directly to BCBSVT using
modifier “GY”. For full details see the modifier section in Section 6.
•Do not send duplicate claims. Check claim status on the BCBSVT
secure provider site, or by calling Customer Service before
submitting a Medicare secondary or supplemental claim. If you
are not checking the status, wait at least 30 days from the date
of Medicare processing before resubmitting the claim.
43
Special Billing Instructions for Rural Health
Center or Federally Qualified Health Center:
In most cases, you should not have to submit Medicare secondary/
supplemental claims directly to BCBSVT as they cross over directly
to BCBSVT from CMS. Federal Employee Program (FEP) claims
do not cross over at this time and require paper submission.
If you do have a need to submit a Medicare secondary/
supplemental claim to BCBSVT, submit it on paper in the
format you submitted to Medicare (CMS 1500 or UB 04) and
attach the Explanation of Medicare Benefits (EOMB).
Providers who do not accept Medicare Assignment
and are contracted with BCBSVT:
In situations where the member has Medicare as primary
and the provider does not accept Medicare Assignment,
but contracts with BCBSVT, the following will occur:
Members with supplemental insurance: Upon receipt of these
claims, BCBSVT will consider benefits for any member liabilities that
remain as reported by Medicare. These types of members are easily
identified as they have a suffix at the end of their certificate number.
Member with a BCBSVT policy after Medicare (referred to
as secondary coverage): Upon receipt of these claims, BCBSVT
will consider benefits for any outstanding balances and process using
the BCBSVT guidelines. We will reimburse only those amounts that,
when added to amounts received by other sources, equal 100% of the
compensation that would otherwise be due. The provider must write off
any balances between the allowed amount and the charged amount.
Please refer to Section 1, “Services where Medicare is primary,
but provider (1) does not participate/accept assignment and
(2) is contracted with BCBSVT”, for information on what can be
billed to the member and claim submission requirements.
CMS 1500 Claim Form Instructions
Go to www.bcbsvt.com/export/sites/BCBSVT/
provider/resources/forms/PDFs/CMS-1500
instructions.pdf for a link to complete instructions.
Important Reminders Regarding Submission of the CMS 1500
To submit COB claims, attach a copy of the explanation of
benefits form from the primary insurance carrier to the CMS
1500 Claim Form and complete boxes 9, 9a-d, 11d and 29.
•Only one service per line and only six lines of service
are allowed on a claim form.
•List only one provider per claim.
•Individual rendering provider number must be
indicated in item 24k of the form.
•Claim must be submitted within 180 days of service being rendered.
•Do not enter the amount of the patient’s
payment or the deductible in Item 29.
Remittance Advice
Remittance Advice (RA) are issued weekly to participating or innetwork providers who submit claims. The RA’s are designed to
help providers identify claims that have been processed for their
patients. The RA includes claims that are paid, denied or adjusted.
We send a separate Remittance Advice ( RA) and payment
check or electronic fund transfer (EPT)/direct deposit
for each of the following benefit programs:
•Federal Employee Program (FEP)
•Indemnity, CBA Blue, Medicomp, Vermont Health Partnership (VHP)
•Medicare Supplemental Program
•The Vermont Health Plan (TVHP)
•BlueCard & Host Regional (NEHP)
Remittance advices are available in either paper or electronic
format (PDF or 835). Paper remits and checks are mailed using
the US Postal Service. Electronic remits are also available on the
secure area of the bcbsvt.com website. Please note: Paper remits
are not mailed to practices/providers who receive electronic fund
transfer (EFT)/direct deposit. See the reimbursement information
in Section 1 for details on how to sign up for EFT/direct deposit.
Electronic remits are retained for seven years.
Claim Status
After initial submission, including Medicare crossover claims, wait at
least thirty (30) days before requesting information on the status of the
claim for which you have not received payment or denial. After thirty
(30) days there are several options to check the status of a claim:
1. Unlimited inquires may be made through the BCBSVT website,
www.bcbsvt.com;
2. See Section Two (2) of this Manual for information on how to access
claims information on the web.
44
3. Call one of the service lines listed in Section One (1) of this Manual; or
4. Submit a Payment Inquiry Form
Remittance Advice, Discount of Charge Reporting
Due to our system calculations, service(s) that price at a
discount off charge reports the allowed amount as the charged
amount. The line is reported with a HIPAA adjustment code.
Paper remits report a 45, and 835’s (I&P) report a 131.
Example:
If the provider bills in a charge of $100.00 and the pricing is discount
off charge (say 28%), the allowance is $72.00. On the remit, the
allowance will report $100; the payment (assuming no member
liability) will reflect $72.00 and a provider write off of $28.00.
Resubmission of Returned Claims
Returned claims are those that are returned to a provider either with
a paper cover letter or on a paper/electronic error report informing
the provider that the claim did not process through to a remittance
advice—if a vendor or clearinghouse submits a claim on a provider’s
behalf, the report is returned directly to the vendor and not the provider
office. Claims could be returned for various reasons including, but not
limited to: member unknown, NPI not on file, or incorrect place of
service. For electronic submitters, a Returned Claim may be resubmitted
electronically after the area of the claim that was in error is corrected.
For paper submissions, resubmit as a clean claim only after correcting the
area of the claim that was in error. Never mark the resubmitted claims
with any type of message as it will only result in a delay in processing.
Corrected Claim
A Corrected Claim is one which has processed through
to a remittance advice, but requires a specific correction
such as, but not limited to, change in units, change in
date of service, billed amount or CPT/HCPCS code.
Complete details on how to submit corrected claims is
located on our provider website at www.bcbsvt.com under
reference guides, Correct claim submission guidelines.
Corrected Claims for Exchange Members within their grace period:
Corrected claims (UB 04 bill types) or claim adjustments (UB 04 or
CMS 1500 types) for claims that are in month 2 or 3 of their grace
period cannot be processed. They should not be submitted to BCBSVT
until after the claim has processed and reported to a remittance
advice. If you do happen to submit a correct claims or adjustment
it will be returned directly to your office advising the member is
within their grace period and the correct claim or adjustment can
be submitted after payment is made or termination is complete.
For full details on Exchange grace periods, see “grace
period for individual through the exchange”.
BCBSVT Provider Claim Review
A Claim Review is a request by a provider for review of a
claim which has been processed and the provider is not in
agreement with the contract rate, amount of reimbursement,
or payment policy (for example denial for duplicate services for
which the provider believes were clinically appropriate).
A Claim Review request may be made directly by contacting our Customer
Service Department or filed in writing using the Payment Inquiry Form.
Claim Review requests must be made within one hundred eighty
(180) days from the original Remittance Advice date. All supporting
documentation specific to the Claim Review must be supplied at the time
of submission of the Provider Inquiry Form. The Claim Review request will
be reviewed and a letter of response provided pursuant to BCBSVT Policies.
Member Confidential Communications:
BCBSVT members have the ability to file for a
confidential communication process.
Facilities and/or providers working with the members on this process
need to have a strong process in place to notify your billing staff and
have all claims submissions placed on hold until BCBSVT has confirmed
the process is complete and claim(s) are ready to be submitted.
See Section 3 for full details.
Claim Specific Guidelines
Applied Behavior Analysis (ABA) Special Instructions
It is the intent and prerogative of BCBSVT and TVHP to pay for
necessary medical and surgical services, under our member contracts
and keeping with accepted and ethical medical practice.
BCBSVT and TVHP use the HCFA Common Procedure Coding
System (HCPCS) and The American Association’s Current Procedural
Terminology (CPT). Diagnostic coding must be according to
the International Classification of Diseases (ICD‑9‑CM).
The Plan(s) require CPT, HCPC, ICD-9-CM and DSM-III R diagnostic
codes to ensure that claims are processed promptly and accurately.
This section provides guidelines for use in submitting claims for
services provided to BCBSVT, TVHP and BlueCard members (members
45
from other Blue Plans). Topics are listed alphabetically. Notifications
on revisions to this section will be posted to the provider website or
published in FinePoints, the BCBSVT/TVHP newsletter for providers.
BlueCard Claims
Medical policies and benefit restrictions related to these and other medical
services are available at
www.bcbsvt.com or by calling your provider relations consultant.
ClaimCheck
The BCBSVT Payment Policy Manual includes policies that document the
principles used to make payment policy, as well as policies documenting
specific billing/coding guidelines and documentation requirements.
The Payment Policy Manual overview and payment policies are available
on our secure provider website at
www.bcbsvt.com or by calling your provider relations consultant.
BCBSVT reserves the right to conduct audits on any provider and/
or facility to ensure compliance with the guidelines stated in medical
policy and/or payment policies. If an audit identifies instances of
non-compliance with a medical policy and/or payment policy,
BCBSVT reserves the right to recoup all non-compliant payments.
H0032
H2014
H2019
H2021
Code
HP
HO
HN
HM
46
Applied Behavior Analysis
(ABA) Initial Assessment
and Plan Development
Supervision of ABA follow-up
or therapeutic staff support
Applied Behavior Analysis
(ABA) follow-up and
reassessment
Applied Behavior Analysis
(ABA) follow-up and
reassessment
This system applies all of the existing industry standard
criteria and protocols for Current Procedural Terminology
(CPT), Health Care Procedure Coding System (HCPCS) and the
Internal Classification of Diseases (ICD-10_CM) manuals.
The ClaimCheck software is upgraded twice a year; in April and October.
An advanced notice is posted to the news area of our provider website at
www.bcbsvt.com, advising of the upgrade date and any related details.
These are the three most prevalent coding irregularities that we find:
Mutually Exclusive: Two or more procedures that by practice
standards would not be billed to the same patient on the same day.
BCBSVT requires the submission of the following
codes, units and modifiers.
Description
BCBSVT utilizes McKesson ClaimCheck software to assure accuracy and
consistency in claims processing for all of our product lines (BCBSVT,
Federal Employee Program and BlueCard) for both professional
(CMS 1500) and outpatient facility (UB04) based claims.
Unbundling: Two or more individual CPT or HCPCS codes
that should be combined under a single code or charge.
Claim Submission and
Reimbursement Guidelines
Code
See Section 7 for details
Units
Inclusive Procedures: Procedures that are considered part
of a ­primary procedure and not paid as separate services.
Per hour up
to 4 hours
Consistent application of these rules improves the
accuracy and fairness of our payment of benefits.
Per 15 minutes
Per 15 minutes
Per 15 minutes
Description
Doctoral Level (board certified behavior analyst)
Masters degree level (board certified behavior analyst)
Applied Behavior Analysis (ABA)
follow-up and reassessment
Less than bachelor’s degree level
(non‑certified support staff)
ClaimCheck also applies the National Correct Coding Initiative (NCCI)
Edits for the processing of both facility and professional claims. Our
updates of the NCCI will not align with the Centers for Medicare and
Medicaid Services (CMS), we will always be one version behind.
In addition, ClaimCheck applies the appropriate Relative Value
Unit for each service performed and processed in order of the
RVU value. RVU are constructed by the Centers for Medicare and
Medicaid Services to display the relative intensity of resources
required to care for a broad range of diseases and conditions.
BCBSVT has made available to you Clear Claim Connection™ (C3).
C3 is a web-based application that enables BCBSVT to disclose
claims payment policies, rules and edit rationale to our physician
network. Physicians can access any of this information via our
secure provider website (www.bcbsvt.com). The system can;
increase transparency and help BCBSVT educate our physician
community on conceivably complex medical payment policies.
You can locate C3 as follows:
•www.bcbsvt.com
•Go to the provider web area
•Sign into the secure provider website
•Go to link titled “Clear Claim Connect (C3)
•There are two links: one for professional claim logic and one
for outpatient claim logic, click on the applicable link.”
located on the secure provider portal at www.bcbsvt.com
under BCBSVT policies, payment policies, acupuncture.
Air Ambulance
Claims for air ambulance services must be filed to the Blue Plan
in whose service area the point of pickup ZIP code is located.
NOTE: If you contract with more than one Plan in a
state for the same product type (i.e., PPO or Traditional),
Providers can run claims through C3 for a determination of claims editing in you may file the claim with either Plan.
advance of claim submission, or after claim submission to explain the logic.
We encourage providers to use this tool to better understand the logic
behind claims processing. Please remember, this is not tied to benefits,
payment policies, medical policies, etc., and will only provide claim editing
logic. In addition, the version of editing logic in our claim system does a
claim look back (up to 99 lines) when editing, so if you are inquiring about
a service related to another service, you will want to enter all services in
the look-up tool. For example: If an office visit occurs a day earlier than
a surgery, you would want to enter the office visit and date along with
the surgery and date to make sure there is not any preoperative logic.
ClaimCheck Logic Review: A ClaimCheck Logic Review is a
request by a provider for review of the logic supporting the processing
of claims. Prior to filing for a ClaimCheck review the processing of the
claim should be reviewed through the Clear Claim Connect (C3) tool
on the secure area of the BCBSVT Provider Website. C3 will provide
a full explanation of the logic behind the processing of the claim.
A ClaimCheck Logic Review request may only be
submitted in the following circumstance:
A provider has locally or nationally recognized documentation that
supports other possible logic. If a provider disagrees with the ClaimCheck
logic a request for review may be submitted by calling or writing to your
Provider Relations Consultant within one hundred eighty (180) days from
the original Remittance Advice date. The provider will need to supply
copies of all supporting documentation relied upon for use of a different
logic than that currently in use by BCBSVT. BCBSVT ClaimCheck Committee
will review the information and notify the provider in writing of the final
decision of the Plan. Note: A ClaimCheck Review of a specific claim
should not be filed. If the claim was subject to extreme circumstances the
BCBSVT Provider Claim Review process set forth above should be followed.
If when reviewing a denial of a claim based on ClaimCheck it is determined
that a modifier or CPT code should be added/changed, the claim should
be resubmitted as a Corrected Claim (as described above). BCBSVT stands
behind all ClaimCheck logic and will uphold all denials for routine cases.
Acupuncture
BCBSVT has a payment policy for acupuncture. The policy
defines eligible, billable acupuncture services and how to
bill for those services. Our payment policy for acupuncture is
47
Service
Rendered
Air
Ambulance
Services
How to File (required
fields)
Point of Pick-up ZIP Code:
• Populate item 23 on CMS
1500 Health Insurance Claim
Form, with the 5-digit ZIP
code of the point of pick-up
– For electronic billers,
populate the origin
information (ZIP code of
the point of pick-up), in
the Ambulance
Pick-up Location Loop in
the ASC X12N Health Care
Claim (837) Professional.
Where to File
Example
File the claim
to the Plan in
whose service
area the point of
pick-up ZIP code
is located.*
• The point
of pick-up
ZIP code is in
Plan A service
area.
• The claim
must be filed
to Plan A,
based on the
point of pickup ZIP code.
*BlueCard
rules for claims
incurred in an
overlapping
service area
and contiguous
county apply.
• Where Form CMS-1450 (UB04) is used for air ambulance
service not included with local
hospital charges, populate
Form Locators 39-41, with
the 5-digit ZIP code of the
point of pick-up. The Form
Locator must be populated
with the approved Code and
Value specified by the National
Uniform Billing Committee in
the UB-04 Data Specifications
Manual.
– Form Locators (FL)
39-41
– Code: AO (Special ZIP
code reporting), or its
successor code specified
by the National Uniform
Billing Committee.
– Value: Five digit ZIP Code
of the location from which
the beneficiary is initially
placed on board the
ambulance.
– For electronic claims,
populate the origin
information (ZIP code
of the point of pickup in
the Value Information
Segment in the ASC X12N
Health Care Claim (837)
Institutional.
Allergy
For injection of commercially prepared allergens, use the appropriate
CPT code for administration. For codes indicating “more than
__ test,” the specific number of tests should be indicated
on the claim form in item 24g. 1 unit = 1 test.
Use the appropriate CPT/HCPCS drug code if
billing for the injected material.
48
Ancillary Claim for BlueCard(defined as Durable Medical
Equipment, Independent Clinical Laboratory and Specialty Pharmacy)
You must file ancillary claims to the Local Plan, which is the Plan in
whose service area the ancillary services are rendered, defined as follow:
Independent
Clinical
Laboratory*
Durable
Medical
Equipment
Specialty
Pharmacy*
The Plan in whose service area the specimen was
drawn or collected
*(Place of Service 81 only)
The Plan in whose service area the equipment
was shipped to or purchased at a retail store
The Plan in whose service area the
ordering physician is located *(Specialty
Pharmacy Specialty only)
All Blue Plans use fields on CMS 1500 health insurance claim forms
or 837 professional electronic submissions to identify the Local Plan.
The following information is required on all ancillary claim submissions.
If this information is missing, we will return or reject these claims.
Loop
Local
CMS 1500
Ancillary
on
837
Plan
Box/
Claim Type Identifier Description Electronic
Submission
Independent
Clinical Laboratory
Durable Medical
Equipment
Durable Medical
Equipment
Referring
Provider NPI
Referring
Provider NPI*
If Place of
Service
= Home,
Patient/
Member
Address
Durable Medical If Place of
Equipment
Service
≠ Home,
Service
Facility
Location
or Billing
Provider
Location
Speciality
Referring
Pharmacy
Provider NPI
17B
2310A
17B
2310A
5 or 7
2010CA or
2010BA
32 or 33
2310C or
2010AA
17B
2310A
Not used to identify Local Plan for ancillary claim processing, however
required on all DME claims to support medical record processing.
It is important to note that if you have a contract with the local Plan
as defined above, you must file claims to the local Plan and will
process as participating/network provider claims. If you do not have
a contract with the local Plan, you must still file claims with the local
Plan, but we will consider non-participating/out-of-network claims.
Modifier
-QS
Anesthesia
Anesthesia time begins when the anesthesiologist begins to prepare
the patient for anesthesia care in the operating room or in an
equivalent area, and ends when the anesthesiologist is no longer in
personal attendance, that is when the patient is safely placed under
post-anesthesia supervision. Time that the anesthesiologist, and/or
certified registered nurse anesthetists (CRNAs) or anesthesia assistants
(AAs) is not in personal attendance is considered non-billable time.
Services involving administration of anesthesia should be reported using
the applicable anesthesia five-digit procedure codes (00100 – 01999) and
if applicable the appropriate HCPC National Level II anesthesia modifiers
and/or anesthesia physical status (P1 – P6) modifiers as noted below.
An anesthesia base unit value should not be reported. Time units
should be reported with 1-unit for every 15 minute interval, time
duration of 8 minutes or more constitutes an additional unit.
-QX
-QZ
Modifier
-AA
The following table identifies the source of each component
that is utilized in anesthesia pricing method.
Time Units
Base Unit Value (BUV)
Anesthesia Coefficient
Source of Information
Submitted on the claim by the provider
Obtained from American
Society of Anesthesiologist
(ASA) Relative Value Guide
Blue Cross and Blue Shield of Vermont
(BCBSVT) reimbursement rate
BCBSVT requires the use of the following modifiers as appropriate
for claims submitted by anesthesiologist and/or certified
registered nurse anesthetists (CRNAs) or anesthesia assistants
(AAs) when reporting general anesthesia services.
The term CRNAs include both qualified anesthetists and anesthesia
assistants (AAs), thus from this point forward in guidelines the term CRNA
will be used to refer to both categories of qualified anesthesiologists.
Monitored anesthesia
care services
CRNA service: with medical
direction by a physician*
CRNA service: without medical
direction by a physician
Informational—
Modifier use
will not impact
reimbursement
Allows 50% of fee
schedule payment
based on the
appropriate unit rate
Allows 100% of fee
schedule payment
based on the
appropriate unit rate
Anesthesiologist Modifiers (please note, these modifiers
should always be billed in the first position of the modifier field)
Reimbursement for anesthesia services is based on the American
Society of Anesthesiologist Relative Value Guide method pricing: (time
units + base unit value) x anesthesia coefficient. Base unit values
(BUVs) will automatically be included in the reimbursement.
Component
BCBSVT/TVHP
Business Rules
Description
-QK
-QS
-QY
Description
BCBSVT/TVHP
Business Rules
Anesthesia service
Unusual circumstances when it
performed personally is medically necessary for both
by anesthesiologist
the CRNA and anesthesiologist
to be completely and fully
involved during a procedure,
100% payment for the services
of each provider is allowed. Anesthesiologist would report
–AA and
CRNA–QZ.
Medical direction of Allows 50% of fee schedule
two, three or four
payment based on the
concurrent anesthesia appropriate unit rate
procedures involving
qualified individuals*
Monitored anesthesia Informational—Modifier use
care services
will not impact reimbursement
Medical direction
Allows 50% of fee schedule
of one certified
payment based on the
registered nurse
appropriate unit rate
anesthetist (CRNA) by
an anesthesiologist*
BCBSVT follows The Centers for Medicare and Medicaid Services (CMS)
criteria for determination of Medical Direction and Medical Supervision.
CRNA Modifiers (please note, these modifiers should always
be billed in the first position of the modifier field)
49
Medical Direction
Medical direction occurs when an anesthesiologist is involved in two,
three or four concurrent anesthesia procedures or a single anesthesia
procedure with a qualified anesthetist. The physician should:
1. perform a pre-anesthesia examination and evaluation;
2. prescribe the anesthesia plan;
3. personally participate in the most demanding procedures of the
anesthesia plan, including induction and emergence, if applicable;
4. ensure that any procedures in the anesthesia plan that he or she does
not perform are performed by a qualified anesthetist;
5. monitor the course of anesthesia administration at intervals;
6. remain physically present and available for immediate diagnosis and
treatment of emergencies; and
7. provide indicated post-anesthesia care.
If one or more of the above services are not performed by the
anesthesiologist, the service is not considered medical direction.
Modifier
P1
A normal healthy patient
P2
A patient with mild
systemic disease
P3
A patient with severe
systemic disease
P4
A patient with severe
systemic disease that is a
constant threat to life
P5
A moribund patient who
is not expected to survive
without the operation
P6
A declared brain-dead patient
whose organs are being
removed for donor purposes
Medical Supervision
Medical Supervision occurs when an anesthesiologist is involved
in five or more concurrent anesthesia procedures. Medical
supervision also occurs when the seven required services under
medical direction are not performed by an anesthesiologist.
This might occur in cases when the anesthesiologist:
•Left the immediate area of the operating suite
for more than a short duration;
•Devotes extensive time to an emergency case; or
•Was otherwise not available to respond to the
immediate needs of the surgical patients.
Example: An anesthesiologist is directing CRNAs during three
procedures. A medical emergency develops in one case that demands the
anesthesiologist’s personal continuous involvement. If the anesthesiologist
is no longer able to personally respond to the immediate needs of the
other two surgical patients, medical direction ends in those two cases.
Medical Supervision by a Surgeon: In some small institutions, nurse
anesthetist performance is supervised by the operating provider (i.e.,
surgeon) who assumes responsibility for satisfying the requirement found
in the state health codes and federal Medicare regulations pertaining to
the supervision of nurse anesthetists. Supervision services provided by the
operating physician are considered part of the surgical service provided.
Anesthesia Physical Status Modifiers (please note, these
modifiers should always appear in the second modifier field)
50
Description
BCBSVT/TVHP
Business Rules
Informational—
Modifier use
will not impact
reimbursement
Informational—
Modifier use
will not impact
reimbursement
Informational—
Modifier use
will not impact
reimbursement
Informational—
Modifier use
will not impact
reimbursement
Informational—
Modifier use
will not impact
reimbursement
Informational—
Modifier use
will not impact
reimbursement
Electronic billing of anesthesia: Electronic billing can either be in
minutes or 8 - 15 unit increments. The appropriate indicator would need
to be used to advise if the billing is units or minutes. Please refer to our
online companion guides for electronic billing for specifics. If billing
minutes, our system edits require that 16 or more are indicated. If 15
minutes or less, the claim is returned to the submitter. Claims for 8 - 15
minutes of anesthesia must be billed on paper. Anesthesia reimbursement
is always based on unit increments; therefore, electronic claims submitted
as minutes are translated by the BCBSVT system into 8 - 15 minute unit
increments. Time units are translated; 1-unit for every 8 - 15 minute
interval, time duration of 8 minutes or more constitutes an additional unit.
Paper billing of anesthesia: Anesthesia services billed on
paper can only be billed in unit increments (1-unit for every 8 - 15
minutes interval, time duration of 8 - 15 minutes constitutes an
additional unit). If your claim does not qualify for at least 1-unit
(is less than 8 minutes), it should not be submitted to BCBSVT.
Bilateral Procedures
For bilateral surgical procedures when there is no specific bilateral
procedure code, use the appropriate CPT code for the first service,
and use the same code plus a modifier –50 for the second service.
Biomechanical Exam
Use office visit codes for biomechanical exams.
Breast Pumps
Specific guidelines for benefits and billing are available
on our provider website at www.bcbsvt.com under
“Breast pumps, how to determine benefits”.
Computer Assisted Surgery/Navigation
See Robotic & Computer Assisted Surgery/
Navigation in this section for full details.
Dental Anesthesia:
The BCBSVT medical policy for dental services defines
services and where prior approval and claims are to be
submitted. It has two sections; Part A and Part B.
The first section, “Part A”, defines all the services and requirements
of the medical component for dental. The Part A benefits are
administered by BCBSVT and require the use of Blue Cross
and Blue Shield contracted providers. Prior approval requests
and claim submissions are sent directly to BCBSVT.
The second section, “Part B”, defines all the services and requirements
for the pediatric dental benefits. The Part B benefits are administered
by CBA Blue and require the use of CBA Blue contracted providers. Prior
approval requests and claim submissions are sent directly to CBA Blue.
Time units* need to be reported with 1-unit for every 15 minute
interval. Time duration of 8 minutes or more constitutes an additional
unit. Reimbursement for these dental anesthesia services is based on the
time units billed + base unit value x anesthesia coefficient, therefore; it
is very important that you bill accordingly on one claim line. Base unit
values (BUVs) will automatically be included in the reimbursement.
Note:
•CBA Blue responds to provider inquiries on dental services and claims
related to Part B and BCBSVT respond to member inquiries related to
Part B. Pre-treatment or prior approval forms submitted to CBA Blue
are responded to by CBA Blue using BCBSVT letterhead.
•If services incorporate both Part A and Part B services and prior approval
is required, the prior approval needs to be submitted to BCBSVT. We
will coordinate with CBA Blue for proper processing. Claims can be split
out and sent to both, or if that is not possible, submit directly to BCBSVT
and we will coordinate the processing.
Example: 47 minutes of deep sedation was provided to a patient.
Diagnosis Codes
Bill one line of D9223 with a total of 3 units (the extra 2
minutes are written off per our anesthesia instructions*).
BCBSVT claims process using the first diagnosis code submitted. If you
receive a denial related to a diagnosis code on a BCBSVT claim, and there
is another diagnosis on the claim that would be eligible, you do not
need to submit a corrected claim, just contact our customer service team
either by phone, e-mail, fax or mail and they will initiate a review and/
or adjustment. Or, if the diagnosis is truly in the wrong position, you
may submit a corrected claim updating the placement of the diagnosis.
BCBSVT has designated D9223 & D9243 as multiple unit
codes and they need to be billed accordingly.
*If billing electronically, services can either be in minutes or 8-15
unit increments. The appropriate indicator would need to be
used to advise if the billing is units or minutes. Please refer to
our online companion guides for electronic billing for specifics
or the anesthesia instructions in this section of the provider
manual for detailed instructions on anesthesia billing.
Dental Care
FEP members have limited dental care available through the medical
coverage and also have a supplemental dental policy available to
them at an additional cost. To learn more about FEP dental coverage
and claim submission requirements, refer to Section 9 FEP.
Health Care Exchange members have benefits available for
Pediatric Dental. These members are identified by an alpha
prefix of “ZII” or “ZIG” and are age 21 or under. They are covered
through the end of the year of their 21st birthday.
For BlueCard claims, we send all reported diagnosis code(s) to the
member’s Plan. If you wish to change the order of the diagnosis
codes, you must submit a corrected claim. This corrected claim
adjustment may or may not affect the benefit determination.
Drugs Dispensed or Administered by a
Provider (other than pharmacy)
Claims with drug services must contain the National Drug Code
(NDC) along with the unit of measure and quantity in addition
to the applicable Current Procedural Terminology (CPT) or
Members of an administrative services only (ASO) whose
employer group has purchased dental coverage through BCBSVT
are eligible through the BCBSVT Dental Medical Policy.
51
Health Care Procedure Coding System (HCPCS) codes(s). This
requirement applies to drugs in the following categories:
•administrative
•miscellaneous
•investigational
•radiopharmaceuticals
•drugs “administered other than oral method”
•chemotherapy drugs
•select pathology
•laboratory
•temporary codes
The requirement does not apply to immunization
drugs or to durable medical equipment.
Acceptable values for the NDC Units of
Measurement Qualifiers are as follows:
Unit of
Measure
F2
GR
ME
ML
UN
Description
International Unit
Gram
Milligram
Milliliter
Unit
Please refer to our on-line CMS (item number 24a and 24D), UB04
(form locator 42 and 44) instructions or HIPAA compliant 837I or
837P companion guide (section 1.11, NDC) for full billing details.
We have posted a National Drug Code (NDC) Provider Tool to
our secure provider website. It is intended to assist practices in
determining the unit of measure that needs to be reported to
BCBSVT. The tool is updated semi-annually; February and August.
BCBSVT updates the NDC codes and pricing in February and August. We
require the submission of the claims to align with the current code set.
Durable Medical Equipment
DME rentals require From and To dates on claims, but the dates cannot
exceed the date of billing.
Evaluation and Management reminder
Current Procedural Terminology (CPT) guidelines recognize seven
components, six of which are used in defining the levels of
evaluation and management services. These components are:
•History;
•Examination;
•Medical decision making;
•Counseling;
•Coordination of care;
•Nature of presenting problem; and lastly
•Time.
The first three of these components are considered the key components
in selecting a level of evaluation and management services.
The next three components are considered contributory factors in
the majority of encounters. Although counseling and coordination
of care are important evaluation and management services,
theses services are not required at every patient encounter.
The final component, time, is provided as a guide, however, it is only
considered a factor in defining the appropriate level of evaluation
and management code when counseling and/or coordination of care
dominates the physician/patient and/or family encounter. Time is
defined as face to face time; such as obtaining a history, performing and
examination or counseling the patient. CPT provides a nine step process
that assists in determining how to choose the most appropriate evaluation
and management code. We apply this process when auditing medical and
billing records, and encourage all practices/providers to become familiar
with the nine step process. Remember however, the most important steps,
in terms of reimbursement and audit liability, are verifying compliance
and documentation. If your practice utilizes a billing agent, it is still the
practice’s responsibility to make sure correct coding of claims is occurring.
Please refer to a CPT manual for full details on proper
coding and complete documentation.
Flu Vaccine and Administration
BCBSVT contracted providers, facilities and home health agencies
cannot bill members up front for the vaccine or administration.
The rendering provider, facility or home health agency must
submit the claim for services directly to BCBSVT.
Every member who receives a flu shot must be billed separately. BCBSVT
does not allow for roster billing or billing of multiple patients on one claim.
Both an administration and vaccine code can be billed for the service.
For billing of State-supplied vaccine/toxoid, please refer
to instructions further down in this section.
52
Habilitative Services
Most BCBSVT members have benefits available for habilitative services.
Habilitative services, including devices, are provided for a person to attain
a skill or function never learned or acquired due to a disabling condition.
When providing habilitative services for physical medicine,
occupational or speech therapy a modifier-SZ must be reported,
so services will accumulate to the correct benefit limit.
Each vaccine is administered with a base (CPT 90460) and
an add-on code (CPT 90461) when applicable.
CPT codes 90460 and 90461 allows for billing
of multiple units when applicable.
Single line billing examples with counts
Example A: Single line billing, multiple vaccines with combination toxoids
All other services for habilitative do not have
any special billing requirements.
Line
CPT-4 Description
Home Infusion Therapy (HIT) Drug Services
1
90649
HIT claims are to be billed the same as Drugs dispensed or
administered by a Provider (other than pharmacy). Please
refer to that section of the manual for full details.
2
90460
HIT providers who are on the community home infusion therapy
fee schedule must bill procedure code 90378 (Synigis-RSV) using
the Average Wholesale Price (AWP). If you have questions, please
contact your provider relations consultant at (888) 449-0443.
1
1
Example B: S ingle line billing, multiple vaccines with combination toxoids
Line
CPT-4
1
90710
Hospital Acquired Conditions:
2
90460
See “Never Events, Hospital Acquired Conditions and
Preventable Medical Errors” in this section for full details.
3
90461
Hub and Spoke System for Opioid Addiction
Treatment (Pilot program)
Human papilloma virus
vaccine quadriv 3 dose im
Immunization Administration
18 yr any route 1st vac/toxoid
Unit Count
Description
Unit Count
Measles mumps rubella
1
varicella vacc live subq
Immunization Administration through 1
18 yr any route 1st vac/toxoid
Immunization Administration through 3
18 yr any route ea addl vac/toxoid
Example C: Single line billing, multiple vaccines with combination toxoids
BCBSVT has a payment policy for the Hub and Spoke System for Opioid
Addiction Treatment. The policy defines what the pilot program is,
benefit determinations and billing guidelines and documentation.
Our payment policy for Hub and Spoke System for Opioid Addiction
Treatment is located on the secure provider portal at www.bcbsvt.com
under BCBSVT policies, payment policies, Hub and Spoke.
Line
CPT-4
Description
Unit Count
1
2
90698
90670
1
1
3
90680
Immunization Administration
4
90460
5
90461
Dtap-hib-ipv vaccine im
Pneumococcal conj
vaccine 13 valent im
Rotavirus vaccine pentavalent
3 dose live oral
Immunization Administration through
18 yr any route 1st vac/toxoid
Immunization Administration through
18 yr any route ea addl vac/toxoid
CPT codes 90460 and 90461 should only be reported when a physician or
other qualified health care professional provides face-to-face counseling
to the patient and family during the administration of a vaccine. This faceto-face encounter needs to be clearly documented to include scope of
counseling and who provided counseling (include title(s)) to patient and
parents/caregiver. Proper signatures are also required to verify level of
provider qualification. Documentation is to be stored in the patient’s
medical records.
Qualified health care professional does not include
auxiliary staff, such as licensed practical nurses, nursing
assistants, and other medical staff assistants.
1
3
4
If a patient of any age presents for vaccinations, but there
has been no face-to-face counseling, the administration(s)
must be reported with codes 90471 – 90474.
See Ancillary Claims for BlueCard.
Use the appropriate CPT code for administration of the
injection. If applicable, submit the appropriate CPT and/
or HCPCS code for the injected material.
53
Inpatient Hospital Room and Board, Routine
Services, Supplies and Equipment:
BCBSVT has a payment policy for the Inpatient Hospital Room and Board,
Routine Services, Supplies and Equipment. The policy provides a description,
benefit determinations and billing guidelines and documentation. Our
payment policy for Inpatient Hospital Room and Board, Routine Services,
Supplies and Equipment is located on the secure provider portal at
www.bcbsvt.com under BCBSVT policies, payment policies, Inpatient
Hospital Room and Board, Routine Services, Sup;lies and Equipment.
Incident To
Also referred to at times as supervised billing is not allowed by
BCBSVT. Providers who render care to our members must be
licensed, credentialed and enrolled. Exceptions are: Physical Therapy
Assistants, Occupational Therapy Assistants and Mental Health
Trainees (who meet the requirements defined in our policies).
Locum Tenens
Must be enrolled (See Section 1 for details.) All services rendered by a locum
tenens must be billed using their assigned NPI number in form locator 24J.
Laboratory Handling
Use the appropriate CPT code for handling charges when sending a
specimen to an independent laboratory (not owned or operated by the
physician) or hospital laboratory, and the claim for the laboratory work is
submitted by the physician. Use place of service 11 in CMS 1500 item 24b.
Laboratory Services (self-ordered by patient):
We require all laboratory services be ordered by a qualified
health care provider. If a patient has self-ordered laboratory
services(s), claim(s) cannot be billed to BCBSVT. The member
is financially liable and must be billed directly.
Maternity
If a Physician provides all or part of the antepartum patient care but
does not perform delivery, the following CPT codes are to be used:
Antepartum Care for visit 1-3, use appropriate Evaluation
and Management code applicable for each visit.
Antepartum Care for visit 4 -6, use CPT code 59425. This code
and reimbursement is inclusive of all 3 visits. (visit 4 – 6).
Antepartum Care for visit 7 on, use CPT code 59426. This code
and reimbursement is inclusive of visits 7 forward.
54
For other services, use appropriate CPT coding.
Modifiers
The following payment rules apply when using these modifiers:
•Modifier AS (physician assist, nurse practitioner or clinical nurse
specialist services for assistant surgery)—25% of allowed charge
and 12.5% of allowed charge for each secondary procedure
•Modifier GY (item or service statutorily excluded does not meet the
definition of any Medicare benefit for non-Medicare insurers, and is not a
contracted benefit). The GY modifier allows our system to recognize that
the service or provider is statutorily excluded and to bypass the Medicare
explanation of payment requirement. The GY modifier can only be used
when submitting claims for Medicare members when the service or provider
is statutorily excluded by Medicare.
BlueCard claims with a GY modifier need to be submitted directly to BCBSVT.
The submission of these claims to BCBSVT allows us to apply your contracted
rate so the claims will accurately process according to the member’s benefits.
•In addition to the GY modifier, the claim submission (paper or electronic)
must indicate that Medicare is the member’s primary carrier.
•Claims that cross over to another Blue Plan from Medicare and contain
services with a GY modifier will not be processed by the member’s Blue
plan. Instead, either a letter or remittance denial will be issued alerting
you the claim must be submitted to your local Plan, BCBSVT. We do
this so that our local Plan pricing is applied. Services without the GY
process using Medicare’s allowance; services with the GY needs ours.
•These claims will be returned or rejected with denial code 109 (claim
not covered by this payer/contractor) on the 835 or paper remits. The
paper remits will provide further information by way of remark code
N418 (Misrouted claim. See the payer’s claim submission instructions).
•When submitting Medicare previously processed claims directly to
BCBSVT, include the original claim (with all lines, including those
without the GY modifier) and the Explanation of Medicare Benefits
lines that have previously paid through the member’s Blue Plan
will deny as duplicate and the lines with the GY modifiers will be
processed according to the benefits the member has available.
•Modifier GZ (item or services expected to be denied as not reasonable
and necessary) is used as informational only and will not be reimbursed.
This ill report through to the remittance advice and report a HIPAA denial
reason code 246 “This non-payable code is for required reporting only”.
•Modifier QK (Medical direction of two, three or four concurrent
anesthesia procedures involving qualified individuals)—50% of
fee schedule payment based on the appropriate unit rate
•Modifier QX (CRNA service: with medical direction by a physician)—50%
of fee schedule payment based on the appropriate unit rate
•Modifier QY (Medical direction of one certified registered
nurse anesthetist (CRNA) by an anesthesiologist)—50% of
fee schedule payment based on the appropriate unit rate
•Modifier SZ (habilitative services) - When providing habilitative services
for physical medicine, occupational or speech therapy a modifier-SZ must
be reported, so services will accumulate to the correct benefit limit.
•Modifier 54 (surgical care only)—85% of allowed
charge for primary surgical procedure
•Modifier 55 (postoperative management only)—10%
of allowed charge for primary surgical procedure
•Modifier 56 (preoperative management only)—5%
of allowed charge for primary surgical procedure
•Modifier 81 (minimum assistant surgeon)—10% of allowed
charge and 5% of allowed charge for each secondary procedure
•Modifier 82 (assistant surgeon, when qualified resident
surgeon is not available)25% of allowed charge and 12.5% of
allowed charge for each secondary procedure
Never Events, Hospital Acquired Conditions
and Preventable Medical Errors
Modifier 22 requires that office and/or operative notes be submitted
with the claim. Claims without office and/or operative notes, if payable,
reimburse at a lower level. Please refer to -22 Modifier Payment Policy
on the secure provider website located under www.bcbsvt.com
under BCBSVT policies, payment policy for complete guidelines.
Providers should always bill a defined code when one is available.
If one is not available, use an unlisted service (NEC or NOS),
provide a description of the service along with office and/or
operative notes. The note must accompany the original claim.
Modifiers -80, -82, and AS are only allowed when a surgical
assistant assists for the entire surgical procedure. Medical
records must support the attendance of the assist from the
beginning of the surgery until the end of the procedure.
PTA’s are expected to practice within the scope of their license. Their services
must be directly supervised by a Physical Therapist. The supervising physical
therapist needs to be in the same building and available to the PTA at
the time patient care is given. Medical notes must be signed off by the
supervising therapist. Claims for PTA services must be submitted under
the supervising Physical Therapist’s rendering national provider identifier.
Modifier 81 is only allowed when the surgical assist
is present for a part of the surgical procedure.
Modifiers for Anesthesia, please refer to
Anesthesia section for specifics on usage.
National Drug Code (NDC)
The reporting of an NDC is required for some claim types. Refer to the section
in this manual titled:
Drugs Dispensed or Administered by a Provider (other
than pharmacy) or Home Infusion Therapy.
The BCBSVT Quality Improvement Policy, Never Events, Hospital Acquired
Conditions and Preventable Medical Errors Reporting and Payment Policy
provides all the details of what conditions are considered Never Events and
Hospital Acquired Conditions, investigations, coding requirements and audits.
The policy is located on the secure provider portal at www.bcbsvt.com
under BCBSVT Policies then the Quality Improvement link. Or, you
can call your provider relations consultant for a paper copy.
Providers and facilities are required to report these occurrences within 30 days
from discovery of the event to BCBSVT’s quality improvement coordinator at
[email protected]. The e-mail needs to include the patient’s
name, BCBSVT ID number, date of service involved, type of service, name of
attending physician and the name of person to contact if there are questions.
Claims for these services should be submitted to BCBSVT/TVHP for
inpatient claims the present on admit indicator must be populated
accordingly. BCBSVT will not reimburse for any of the related charges.
The provider and/or facility will be financially responsible for the
cost of the extra care associated with the treatment of a BCBSVT
or TVHP member following the occurrence of a never event.
Not elsewhere classified (NEC)
Not otherwise classified (NOS)
Physical Therapy Assistant (PTA)
Observation Services
BCBSVT has a payment policy for Observation Services. The
policy provides a description, eligible and ineligible services, and
billing guidelines. Our payment policy for Observation Services is
located on the secure provider portal at www.bcbsvt.com under
BCBSVT policies, payment policies, Observation Services.
Occupational Therapy Assistant (OTA)
OTA’s are expected to practice within the scope of their license.
Their services must be directly supervised by an Occupational Therapist.
The supervising occupational therapist needs to be in the same
55
building and available to the OTA at the time patient care is given.
Medical notes must be signed off by the supervising therapist.
Claims for OTA services must be submitted under the supervising
Occupational Therapist’s rendering national provider identifier.
Place of Service
03 - used to identify services in a school setting or school owned infirmary
for services the provider has contracted directly with the school to provide.
11 - used for office setting or services provided in a school
setting or school owned infirmary when the provider is not
contracted with the school to provide the services.
See Ancillary Claims for BlueCard
State Supplied Vaccine/Toxoid
Must be submitted for data reporting purposes. Use the appropriate CPT
code for the vaccine/toxoid and the modifier “SL” (state supplied vaccine)
and a charge of $0.00. If you submit through a vendor or clearinghouse
that cannot accept a zero dollar amount, a charge of $0.01 can be used.
Subsequent Hospital Care
Subsequent hospital care CPT codes (99231, 99232, 99233)
are “per day” services and need to be billed line by line.
Pre-Operative and Post-Operative Guidelines:
Supervised Billing
Some surgical procedures have designed pre and/or post-operative
periods. For those procedures (and associated timeframes) if an
evaluation and management service is reported, the service will deny.
Also referred to at times as incident to is not allowed by BCBSVT.
Providers who render care to our members must be licensed,
credentialed and enrolled. Exceptions are: Physical Therapy
Assistants, Occupational Therapy Assistants and Mental Health
Trainees (who meet the requirements defined in our policies).
To determine if a surgery qualifies for pre and/or post-operative periods,
use the clear claim connect (C3) tool on the secure provider website.
Enter in the surgical code being performed along with the evaluation
d management code. You will need to make sure you indicate on
each service line the specific date it will be or has been performed. Or,
we have a complete listing on the secure provider website under the
resource center, clinical manuals, pre and post-operative manual.
Preventable Medical Errors:
See “Never Events, Hospital Acquired Conditions and
Preventable Medical Errors” in this section for full details.
Provider-Based Billing
BCBSVT does not allow for provider-based billing (i.e.
billing a “facility charge” in connection with clinic services
performed by a physician or other medical professional). Our
payment policy for Provider-Based Billing is located on the
secure provider portal at www.bcbsvt.com under BCBSVT
policies, payment policies, provider based billing.
Robotic & Computer Assisted Surgery/Navigation
BCBSVT does not provide benefits for Robotic & Computer Assisted
Surgery/Navigation. Our payment policy for Robotic & Computer
Assisted Surgery/Navigation is located on the secure provider
portal at www.bcbsvt.com under BCBSVT policies, payment
policies, Robotic & Computer Assisted Surgery/Navigation.
“S” Codes
Submit using the appropriate CPT/HCPCS code. Charges submitted with
an unspecified CPT code (99070) will be denied as non-covered.
Specialty Pharmacy Claims
56
Supplies
Submit using the appropriate CPT/HCPCS code. Charges submitted with
an unspecified CPT code (99070) will be denied as non-covered.
Surgical Assistant
Benefits for one assistant surgeon may be provided during an
operative session. In the event that more than one physician assists
during an operative session, the total benefit for the assistant will
not exceed the benefit for one. Please use appropriate CPT coding.
Not all surgeries qualify for a surgical assistant. To determine if the assist
you are providing is eligible for consideration, use the clear claim connect
(C3) tool on the secure provider website, or review the listing of codes that
always or never allow for a surgical assist on the secure provider website
under the resource center, clinical manuals, assistant surgeon manual.
Surgical Trays
When billing for a surgical tray, members will need to bill
HCPCS level II code A4550 along wit the appropriate fee for
the surgical tray. No modifiers or units are allowed.
Surgical tray benefits will only be considered when billed in
conjunction with any surgical procedure for which use of a
surgical tray is appropriate, when the procedure is performed in
a physician’s office rather than a separate surgical facility.
To determine if a surgical tray is eligible for consideration, use the clear
claim connect (C3) tool on the secure provider website, enter in the
services being performed along with the surgical tray code, or review the
listing of codes that never allow for a surgical tray on the secure provider
website under the resource center, clinical manuals, surgical tray manual.
Telemedicine
BCBSVT has a payment policy for telemedicine. The policy
defines eligible telemedicine services and how the services
need to be billed. Our payment policy for telemedicine is
located on the secure provider portal at www.bcbsvt.com
under BCBSVT policies, payment policies, telemedicine.
Unit Designations
Each CPT & HCPCS code has a unit designation. The designation is single
or multiple. If the code is designated as single unit and more than one
services was provided, each service needs to be billed on their own line.
If a code has a multiple unit designation and more than
one service was provided, you need to bill on a single
line and indicate the amount of units provided.
We have a list of codes and their unit designations available on
our provider website at www.bcbsvt.com/provider. The list is
not all inclusive. If you do not locate your code on the list, contact
our customer service team and they will be able to advise.
The unit designation list is updated quarterly to align with
the AMA’s updates for new, deleted and revised codes.
Urgent Care Clinic
BCBSVT has a payment policy for Urgent Care Clinics. The policy defines
what an urgent care clinic is (free standing or hospital based) and how
the services need to be billed. Our payment policy for Urgent Care
Clinic is located on the secure provider portal at www.bcbsvt.com
under BCBSVT policies, payment policies, Urgent Care Clinic
Vision Services
Members covered through the Healthcare Exchange or employees
with the State of Vermont may have vision services available to
them. We have created quick overview documents that define
the services that are eligible and where claims need to be
submitted. The overview documents are located on our secure
website under resources, reference guides, vision services.
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Section 7
The BlueCard™ Program
Makes Filing Claims Easy
Introduction
c. Accounts Exempt from the BlueCard Program
The following claims are excluded from the BlueCard Program:
•stand-alone dental
•prescription drugs and
•the Federal Employee Program (FEP).
How Does the BlueCard Program Work?
As a participating provider of Blue Cross and Blue Shield of Vermont you
may render services to patients who are national account members of other How to Identify Members
Blue Cross and/or Blue Shield Plans, and who travel or live in Vermont.
a. Member ID Cards
This manual is designed to describe the advantages of the
When members of another Blue Plan arrives at your office or facility, be
program, while providing you with information to make filing
sure to ask them for their current Blue Plan membership identification card.
claims easy. This manual offers helpful information about:
The main identifier for out of area members is the
•Identifying members
alpha prefix. The ID cards may also have:
•Verifying eligibility
•PPO in a suitcase logo, for eligible PPO members
•Obtaining pre-certifications/pre-authorizations
•Blank suitcase logo
•Filing claims and
•Who to contact with questions
What is the BlueCard™ Program?
a. Definition
The BlueCard program is a national program that enables members
obtaining health care services while traveling or living in another Blue Cross
and Blue Shield Plan’s area to receive all the same benefits of their
contracting BCBS Plan, including provider access and discounts on services
negotiated by the local plans. The program links participating health care
providers and the independent BCBS Plans across the country and around
the world through a single electronic network for claims processing.
The program allows you to submit claims for patients from
other Blue Plans, domestic and international, to BCBSVT.
BCBSVT is your sole contact for claims payment,
problem resolution and adjustments.
b. BlueCard Program Advantages to Providers
The BlueCard Program allows you to conveniently submit
claims for members from other Blue Plans, including
international Blue Plans, directly to BCBSVT.
BCBSVT will be your one point of contact for
all of your claims-related questions.
BCBSVT continues to experience growth in out-of‑area membership
because of our partnership with you. That is why we are committed
to meeting your needs and expectations. In doing so, your
patients will have a positive experience with each visit.
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Important facts concerning member IDs:
•A correct member ID number includes the alpha prefix (first three
positions) and all subsequent characters, up to 17 positions total.
This means that you may see cards with I.D. numbers between
6 and 14 numbers/letters following the alpha prefix.
•Do not add/delete characters or numbers within the member ID.
•Do not change the sequence of the characters following the alpha prefix.
•The alpha prefix is critical for the electronic routing of specific
HIPAA transactions to the appropriate Blue Plan.
•Some Blue Plans issue separate identification numbers to members with
Blue Cross (Inpatient) and Blue Shield (Professional) coverage. Member ID
cards may have different alpha prefixes for each type of coverage.
As a provider servicing out-of-area members, you
may find the following tips helpful:
•Ask the member for the most current I.D. card at every visit. Since new
I.D. cards may be issued to members throughout the year, this will ensure
tha you have the most up-to-date information in your patient’s file.
•Verify with the member on the I.D. card is not his/her
Social Security Number. If it is, call the BlueCard Eligibility
line at (800) 676-BLUE to verify the I.D. number.
•Make copies of the front and back of the member’s I.D. card
and pass the key information on to your billing staff.
•Remember: Member I.D. numbers must be reported exactly as
shown on the I.D. card and must not be changed or altered. Do not
add or omit any characters from the member’s I.D. numbers.
Alpha Prefix
The three-character alpha prefix at the beginning of the member’s
identification number is the key element used to identify and
correctly route claims. The alpha prefix identifies the Blue Plan
or national account to which the member belongs. It is critical
for confirming a patient’s membership and coverage.
NOTE: The Canadian Association of Blue Cross Plans and its
members are separate and distinct from the Blue Cross and
Blue Shield Association and its members in the U.S.
Sample Foreign ID Cards
The prefix is followed by the member identification number.
It can be any length, and can consist of all numbers, all
letters or a combination of both letters and numbers.
To ensure accurate claim processing, it is critical to capture all ID card
data. If the information is not captured correctly, you may experience a
delay with the claim processing. Please make copies of the front and the
back of the I.D. card, and pass the key information to your billing staff.
MEMBER NAME
CHRIS B. HALL
BS PLAN
915
BC PLAN
415
RESTAT
0451
IDENTIFICATION NUMBER
XYZ123456789X YZ
GROUP NUMBER
00000000
The three-character alpha prefix.
The “suitcase” logo may appear anywhere
on the front of the card..
If you are unsure about your participation status, call BCBSVT.
b. Consumer Directed Health Care and Health Care Debit Cards
MEMBER NAME
CHRIS B. HALL
BS PLAN
915
BC PLAN
415
RESTAT
0451
IDENTIFICATION NUMBER
XYZ123456789X YZ
GROUP NUMBER
00000000
PREADMISSION REVIEW REQUIRED
Sample ID Cards
Occasionally, you may see identification cards from foreign Blue
members residing abroad or foreign Blue members. These ID
cards will also contain three-character alpha prefixes. Please treat
these members the same as domestic Blue Plan members.
Consumer Directed Health Care (CDHC) is a broad umbrella term that refers
to a movement in the health care industry to empower members, reduce
employer costs, and change consumer health care purchasing behavior.
Health plans that offer CDHC provide the member with additional
information to make an informed and appropriate health care
decision through the use of member support tools, provider
and network information, and financial incentives.
Members, who have CDHC plans often carry health care debit
cards that allow them to pay for out-of-pocket costs using funds
from their Health Reimbursement Arrangement (HRA), Health
Savings Account (HSA) or Flexible Spending Account (FSA).
59
Some cards are “stand-alone” debit cards to cover out-of-pocket
costs, while others also serve as a member ID card with the
member ID number. These debit cards can help you simplify
your administration process and can potentially help:
•Reduce bad debt
•Reduce paper work for billing statements
•Minimize bookkeeping and patient-account
functions for handling cash and checks
•Avoid unnecessary claim payment delays
The card will have the nationally recognized Blue logos, along with
the logo from a major debit card logo such as MasterCard® or Visa.®
Sample stand-alone Health Care Debit Card
Sample combined Health Care Debit
Card and Member ID Card
The cards include a magnetic strip so providers can swipe the card
at the point of service to collect the member cost sharing amount
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(i.e. co-payment). With the health debit cards, members can pay for
co-payments and other out-of-pocket expenses by swiping the card
though any debit card swipe terminal. The funds will be deducted
automatically from the member’s appropriate HRA, HSA or FSA account.
Combining a health insurance ID card with a source of payment
is an added convenience to members and providers. Members
can use their cards to pay outstanding balances on billing
statements. They can also use their cards via phone in order to
process payments. In addition, members are more likely to carry
their current ID cards, because of the payment capabilities.
If your office accepts credit card payments, you can swipe the card at
the point of service to collect the member’s co-payment, coinsurance or
deductible amount. Simply select “credit” when running the card through
for payment. No PIN is required. The funds will be sent to you and will be
deducted automatically from the member’s HRA, HAS or FSA account.
Helpful Tips
•Carefully determine the member’s financial responsibility before
processing payment. You can access the member’s accumulated
deductible by contacting the BlueCard Eligibility line at (800)
676-BLUE (2583) or by using the local Plan’s online services.
•Ask members for their current member ID card and regularly
obtain new photocopies (front and back) of the member ID
card. Having the current card will enable you to submit claims
with the appropriate member information (including alpha
prefix) and avoid unnecessary claims payment delays.
•If the member presents a debit card (stand-alone or combined), be
sure to verify the out of pocket amounts before processing payment:
•Many plans offer well care services that are payable under the
basic health care program. If you have any questions about the
member’s benefits or to request accumulated deductible information,
please contact (800) 676-BLUE (2583).
•You may use the debit card for member responsibility for medical
services provided in your office.
•You may choose to forego using the debit card and submit the claims
to BCBSVT for processing. The Remittance Advice will inform you of
member responsibilities.
•All services, regardless of whether or not you’ve collected the member
responsibility at the time of service, must be billed to the local Plan
for proper benefit determination, and to update the member’s claim
history.
•Check eligibility and benefits electronically (local
Plan’s contact info/Web site address) or by calling
(800) 676‑BLUE (2583) and providing the alpha prefix.
•Please do not use the card to process full payment up front. If you
have any questions about the member’s benefits, please contact
(800) 676-BLUE (2583), or for questions about the health care debit
card processing instructions or payment issues, please contact the
toll‑free debit card administrator’s number on the back of the card.
c. Coverage and Eligibility Verification
Verifying eligibility and confirming the requirement’s of the
member’s policy before you provide services is essential to
ensure complete, accurate and timely claims processing.
Each Blue Cross and Blue Shield plan has its own terms of coverage. There
may be exclusions or requirements you are not familiar with. Each plan
may also have a different co-payment application that is based on provider
speciality. For example, a nurse practitioner or physician assistant in a
primary care practice setting may apply a specialist co-payment rather
than a PCP co-payment. Some Blue Plans may exclude the use of certain
provider specialties such as naturopath, acupuncture or athletic trainers.
Some members may have only Blue Cross (Inpatient) or only Blue Shield
(Professional) coverage with their Blue Plan, so verifying eligibility is
extremely important. There are two methods of verification available:
Electronic—Submit an electronic transaction via the tool
located on the provider web site at www.bcbsvt.com. Please
refer to the manual located in the section for specific details.
Phone—Call BlueCard Eligibility® 1-800-676-BLUE (2583)
A representative will ask you for the alpha prefix and will connect you
to the membership and coverage unit at the patient’s Blue Cross and/or
Blue Shield Plan.
If you are using the BlueCard Eligibility® line keep in mind that Blue
Plans are located throughout the country and may operate on a
different time schedule than Vermont. You may be transferred to a
voice response system linked to customer enrollment and benefits.
The BlueCard Eligibility® line is for eligibility, benefit and pre-certification/
referral authorization inquiries only. It should not be used for claim
status. See the Claim Filing section for claim filing information.
d. Utilization Review
BCBSVT participating facilities are responsible for obtaining preservice review for inpatient services for BlueCard® members.
Members are held harmless when pre-service review is
required by the account or member contract and not received
for inpatient services. Participating providers must also:
•Notify the member’s Blue Plan within 48 hours when a change or
modification to the original pre-service review occurs.
•Obtain pre-service review for emergency and/or urgent admissions
within 72 hours.
Failure to contact the member’s Blue Plan for pre-service review or for a
change of modification of the pre-service review may result in a denial for
inpatient facility services. The remittance advice will report the service as
a provider write-off and the BlueCard® member must be held harmless
and cannot be balance-billed if a pre-service review was not obtained.
On inclusively priced claims, such as DRG or Per Diem, if you bill more days
than were authorized, the full claims may be denied in some instances.
Services that deny as not medically necessary remain member liability.
Pre-service review contact information for a member’s Blue
Plan is provided on the member’s identification card. Preservice review requirements can also be determined by:
•Callling the pre-admission review number on the back of the member’s
card.
•Calling the customer service number on the back of the member’s card
and asking to be transferred to the utilization review area.
•Calling 1.800.676.BLUE if you do not have the member’s card and
asking to be transferred to the utilization review area.
•Using the Electronic Provider Access (EPA) tool available at BCBSVT
provider portal at www.bcbsvt.com. With EPA, you can gain access
to a BlueCard member’s Blue Plan provider portal through a secure
routing mechanism and have access to electronic pre-service review
capabilities. Note: the availability of EPA will vary depending on the
capabilities of each member’s Blue Plan.
Claim Filing
How Claims Flow through BlueCard
Below is an example of how claims flow through BlueCard.
You should always submit claims to BCBSVT.
Following these helpful tips will improve your claim experience:
•Ask members for their current member ID card and regularly obtain
new photocopies of it (front and back). Having the current card enables
you to submit claims with the appropriate member information
(including alpha prefix) and avoid unnecessary claims payment delays.
•Check eligibility and benefits electronically at
www.bcbsvt.com or by calling (800) 676-BLUE (2583).
Be sure to provide the member’s alpha prefix.
•Verify the member’s cost sharing amount before processing
payment. Please do not process full payment upfront.
•Indicate on the claim any payment you collected from the patient.
(On the 837 electronic claim submission form, check field AMT01=F6
patient paid amount; on the CMS1500 locator 29 amount paid; on
UB92 locator 54 prior payment; on UB04 locator 53 prior payment.)
•Submit all * Blue claims to BCBSVT, P.O. Box 186, Montpelier, VT
05601. Be sure to include the member’s complete identification
number when you submit the claim. This includes the
three‑character alpha prefix.Submit claims with only valid
alpha-prefixes; claims with incorrect or missing alpha prefixes
and member identification numbers cannot be processed.
* Providers who render services in contiguous counties, contract with other
Blue Plans or have secondary locations outside the State of Vermont may
not always submit directly to BCBSVT. We have three guides (Vermont and
61
New Hampshire, Vermont and Massachusetts, Vermont and New York) to
assist you with knowing where to submit claims in these circumstances.
These guides are located on our provider website at www.bcbsvt.com.
•In cases where there is more than one payer and a Blue Cross
and/or Blue Shield Plan is a primary payer, submit Other Party
Liability (OPL) information with the Blue Cross and/or Blue claim.
1. Member of
another Blue Plan
receives services
from you,
the provider
2. Provider
submits claim to
the local Blue Plan
3. Local Blue Plan
recognizes BlueCard
member and transmits
standard claim format to
the the member’s Blue Plan
7. Your local
Blue Plan pays
you, the provider
Upon receipt, BCBSVT will electronically route the claim to the
member’s Blue Plan. The member’s Plan then processes the claim
and approves payment; BCBSVT will reimburse you for services.
•Do not send duplicate claims. Sending another claim, or having your
billing agency resubmit claims automatically, actually slows down
the claims payment process and creates confusion for the member.
•Check claims status by contacting BCBSVT at (800) 395-3389.
Medicare Advantage Overview
“Medicare Advantage” (MA) is the program alternative to
standard Medicare Part A and Part B fee-for-service coverage;
generally referred to as “traditional Medicare.”.
MA offers Medicare beneficiaries several product options (similar to those
available in the commercial market), including health maintenance
organization (HMO), preferred provider organization (PPO),
point‑of‑service (POS) and private fee-for-service (PFFS) plans.
All Medicare Advantage plans must offer beneficiaries at least the
standard Medicare Part A and B benefits, but many offer additional
covered services as well (e.g., enhanced vision and dental benefits).
62
In addition to these products, Medicare Advantage organizations may
also offer a Special Needs Plan (SNP), which can limit enrollment to
subgroups of the Medicare population in order to focus on ensuring
that their special needs are met as effectively as possible.
6. Member’s Blue
Plan transmits claim
payment disposition
to your local Blue Plan
4. Member’s Blue
Plan adjudicates
claim according to
member’s benefit plan
5. Member’s Blue Plan
issues an EOB to
the member
Medicare Advantage plans may allow in- and out-of-network
benefits, depending on the type of product selected. Providers should
confirm the level of coverage (by calling 1.800.676.BLUE (2583) or
submitting an electronic inquiry) for all Medicare Advantage members
prior to providing service since the level of benefits, and coverage
rules, may vary depending on the Medicare Advantage plan.
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in
which members typically receive a set of predetermined and prepaid
services provided by a network of physicians and hospitals. Generally
(except in urgent or emergency care situations), medical services are only
covered when provided by in-network providers. The level of benefits,
and the coverage rules, may vary by Medicare Advantage plan.
Medicare Advantage POS
A Medicare Advantage POS program is an option available through
some Medicare HMO programs. It allows members to determine—
at the point of service—whether they want to receive certain
designated services within the HMO system, or seek such services
outside the HMO’s provider network (usually at greater cost to the
member). The Medicare Advantage POS plan may specify which
services will be available outside of the HMO’s provider network.
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers,
but unlike traditional HMO products, it allows members who enroll
access to services provided outside the contracted network of providers.
Required member cost-sharing may be greater when covered
services are obtained out-of-network. Medicare Advantage PPO
plans may be offered on a local or regional (frequently multi-state)
basis. Special payment and other rules apply to regional PPOs.
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan in which the member may
go to any Medicare-approved doctor or hospital that accepts the plan’s
terms and conditions of participation. Acceptance is “deemed” to occur
where the provider is aware, in advance of furnishing services, that
the member is enrolled in a PFFS product and where the provider has
reasonable access to the terms and conditions of participation.
The Medicare Advantage organization, rather than the Medicare
program, pays physicians and providers on a fee-for-services basis
for services rendered to such members. Members are responsible
for cost-sharing, as specified in the plan, and balance billing may
be permitted in limited instance where the provider is a network
provider and the plan expressly allows for balance billing.
Medicare Advantage PFFS varies from the other Blue
Medicare Advantage Medical Savings Account (MSA)
Medicare Advantage Medical Savings Account (MSA) is a
Medicare health plan option made up of two parts. One part is
a Medicare MSA Health Insurance Policy with a high deductible.
The other part is a special savings account where Medicare
deposits money to help members pay their medical bills.
How to recognize Medicare Advantage Members
Members will not have a standard Medicare card; instead,
a Blue Cross and/or Blue Shield logo will be visible on the
ID card. The following examples illustrate how the different
products associated with the Medicare Advantage program
will be designated on the front of the member ID cards:
Eligibility Verification
•Verify eligibility by contacting (800) 676-BLUE (2583) and
providing an alpha prefix or by submitting an electronic
inquiry to your local Plan and providing the alpha prefix.
•Be sure to ask if Medicare Advantage benefits apply.
•If you experience difficulty obtaining eligibility information,
please record the alpha prefix and report it to (local Plan contact).
Medicare Advantage Claims Submission
•Submit all Medicare Advantage claims to BCBSVT.
•Do not bill Medicare directly for any services rendered
to a Medicare Advantage member.
•Payment will be made directly by a Blue Plan.
Traditional Medicare-Related Claims
1. The following are guidelines for ­processing of
Medicare‑related claims:
products you might currently participate in:
•You can see and treat any Medicare Advantage PFFS
member without having a contract with BCBSVT.
•If you do provide services, you will do so under the Terms
and Conditions of that member’s Blue Plan.
•Please refer to the back of the member’s ID card for
information on accessing the Plan’s Terms and Conditions.
You may choose to render services to a MA PFFS member
on an episode of care (claim-by-claim) basis.
•MA PFFS Terms and Conditions might vary for each
Blue Cross and/or Blue Shield Plan and we advise that you
review them before servicing MA PFFS members.
When Medicare is primary payor, submit claims
to your local Medicare intermediary.
•After you receive the Remittance Advice (RA) from Medicare,
review the indicators:
•If the indicator on the RA (claim status code 19) shows that the claim
was crossed-over, Medicare has submitted the claim to the appropriate
Blue Plan and the claim is in progress. You can make claim status
inquiries for supplemental claims through BCBSVT.
•If the claim was not crossed over (indicator on the RA will not show
claim status code 19 and may show claim status code 1), submit the
claim to BCBSVT along with the Medicare remittance advice. You can
make claim status inquiries for supplemental claims through BCBSVT.
•If you have any questions regarding the crossover indicator, please
contact the Medicare intermediary.
2. Do not submit Medicare-related claims to BCBSVT before receiving
an RA from the Medicare intermediary.
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3. If you use Other Carrier Name and Address (OCNA) number on a
Medicare claim, ensure it is the correct for the member’s Blue Plan.
Do ot automatically use the OCNA number for BCBSVT.
4. Do not send duplicate claims. First check a claim’s status by
contacting BCBSVT by phone or through an electronic transaction via
the BlueExchange tool.
Providers in a Border County or Having Multiple Contracts
We have three guides (Vermont and New Hampshire, Vermont
and Massachusetts and Vermont and New York) to assist you with
knowing where to submit claims in these circumstances. These
guides are located on our provider website at www.bcbsvt.com.
International Claims
The claim submission process for international Blue Plan
members is the same as for domestic Blue members.
You should submit the claim directly to BCBSVT.
Medical Records
There are times when the member’s Blue Plan will require medical records
to review the claim. These requests will come from BCBSVT. Please forward
all requested medical records to BCBSVT and we will coordinate with the
member’s Blue Plan. Please direct any questions or inquiries regarding
medical records to Customer Service at (800) 395-3389. Please do
not proactively send medical records with the claim, unless requested.
Unsolicited claim attachments may cause claim payment delays.
Adjustments
Contact BCBSVT if an adjustment is required. We will
work with the member’s Blue Plan for adjustments;
however, your workflow should not be different.
Appeals
Appeals for all claims are handled through BCBSVT. We will coordinate
the appeal process with the member’s Blue Plan, if needed.
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members
receive full benefits and prevent double payment for services when a
member has coverage from two or more sources. The member’s contract
language explains the order for which entity has primary responsibility
for payment and which entity has secondary responsibility for payment.
the claim. This investigation could delay your payment or result in a postpayment adjustment, which will increase your volume of bookkeeping.
b. Other non-Blue health plan is primary and BCBSVT or any other
Blue Plan is secondary, submit the claim to BCBSVT only after receiving
payment from the primary payor, including the explanation of payment
from the primary carrier. If you do not include the COB information with
the claim, the member’s Blue Plan will have to investigate the claim.
This investigation could delay your payment or result in a post-payment
adjustment, which would also increase your volume of bookkeeping.
Claim Payment
1. If you have not received payment for a claim, do not resubmit the
claim because it will be denied as a duplicate. This also causes member
confusion because of multiple Explanations of Benefits (EOBs).
2. If you do not receive your payment or a response regarding your
payment, please call BCBSVT Customer Service at (800) 395‑3389
or submit an electronic transaction via the provider tool at
www.bcbsvt.com to check the status of your claim.
3. In some cases, a member’s Blue Plan may pend a claim because
medical review or additional information is necessary. When resolution
of a pended claim requires additional information from you, BCBSVT
may either ask you for the information or give the member’s Plan
permission to contact you directly.
Claim Status Inquiry
1. BCBSVT is your single point of contact for all claim inquiries.
2. Claim status inquires can be done by:
Phone—by calling BCBSVT customer Service at (800) 395-3389.
Electronically—send an electronic transaction via the provider tool.
Calls from Members and Others with Claim Questions
1. If members contact you, advise them to contact their Blue Plan and
refer them to their ID card for a customer service number.
2. The member’s Plan should not contact you directly regarding claims
issues, but if the member’s Plan contacts you and asks you to submit
the claim to them, refer them to BCBSVT.
Frequently Asked Questions
BlueCard Basics
1. What Is the BlueCard® Program?
BlueCard® is a national program that enables members of one Blue Plan
to obtain healthcare services while traveling or living in another Blue
If you discover the member is covered by more that one health plan, and:
Plan’s service area. The program links participating health care providers
a. BCBSVT or any other Blue Plan is the primary payer, submit other carrier’s with the independent Blue Cross and Blue Shield Plans across the country
name and address with the claim to BCBSVT. If you do not include the COB and in more than 200 countries and territories worldwide through a
information with the claim, the member’s Blue Plan will have to investigate single electronic network for claims processing and reimbursement.
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The program allows you to conveniently submit claims for patients from
other Blue Plans, domestic and international, to your local Blue Plan.
3. What do I do if a member has an identification card without
an alpha prefix?
Your local Blue Plan is your sole contact for claims
payment, problem resolution and adjustments
Some members may carry outdated identification cards that may not
have an alpha prefix. Please request a current ID card from the member.
2. What products and accounts are excluded from the BlueCard
Program?
4. How do I identify international members?
Stand-alone dental and prescription drugs are excluded from
the BlueCard Program. In addition, claims for the Federal
Employee Program (FEP) are exempt from the BlueCard
Program. Please follow your FEP billing guidelines.
Occasionally, you may see identification cards from foreign Blue Plan
members. These ID cards will also contain three-character alpha prefixes.
Please treat these members the same as domestic Blue Plan members.
Verifying Eligibility and Coverage
3. What is the BlueCard Traditional Program?
How do I verify membership and coverage?
A national program that offers members traveling or living
outside of their Blue Plan’s area traditional or indemnity
level of benefits when they obtain services from a physician
or hospital outside of their Blue Plan’s service area.
For Blue Plan members, use the BlueExchange Link on the
BCBSVT web site or call the BlueCard Eligibility® phone
line to verify the patient’s eligibility and coverage:
4. What is the BlueCard PPO Program?
A national program that offers members traveling or living outside of
their Blue Plan’s area the PPO level of benefits when they obtain services
from a physician or hospital designated as a BlueCard PPO provider.
5. Are HMO patients serviced through the BlueCard Program?
Yes, occasionally, Blue Cross and/or Blue Shield HMO members affiliated
with other Blue Plans will seek care at your office or facility. You should
handle claims for these members the same way as you do for BCBSVT
members and Blue Cross and/or Blue Shield traditional, PPO and POS
patients from other Blue Plans—by submitting them to the BCBSVT.
Identifying Members and ID Cards
1. How do I identify members?
When members from Blue Plans arrive at your office or facility, be sure
to ask them for their current Blue Plan membership identification card.
The main identifier for out of area members is the alpha prefix.
The ID cards may also have:
•PPO in a suitcase logo, for eligible PPO members
•Blank suitcase logo
2. What is an “alpha prefix?”
The three-character alpha prefix at the beginning of the member’s
identification number is the key element used to identify and
correctly route claims. The alpha prefix identifies the Blue Plan
or national account to which the member belongs. It is critical
for confirming a patient’s membership and coverage.
Electronic—via the BlueExchange link on the provider secure
website at BCBSVT.com
Phone—Call BlueCard Eligibility® (800) 676-BLUE (2583)
Utilization Review
How do I obtain utilization review?
•Calling the pre-admission review number on the back of the member’s
card.
•Calling the customer service number on the back of the member’s card
and asking to be transferred to the utilization review area.
•Calling 1.800.676.BLUE if you do not have the member’s card and
asking to be transferred to the utilization review area.
•Using the Electronic Provider Access (EPA) tool available at BCBSVT
provider portal at www.bcbsvt.com. With EPA, you can gain access
to a BlueCard member’s Blue Plan provider portal through a secure
routing mechanism and have access to electronic pre-service review
capabilities. Note: the availability of EPA will vary depending on the
capabilities of each member’s Blue Plan.
For Blue Plans members
Phone—Call the utilization management/pre-certification
number on the back of the member’s card. If the utilization
management number is not listed of the back of the member’s
card—call BlueCard Eligibility® (800) 676-BLUE (2583) and
ask to be transferred to the utilization review area.
Claims
1. Where and how do I submit claims?
You should always submit claims to BCBSVT, P.O. Box 186, Montpelier,
VT 05601. Be sure to include the member’s complete identification
number when you submit the claim. The complete identification
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number includes the three-character alpha prefix—do not make
up alpha prefixes. Claims with incorrect or missing alpha prefixes
and member identification numbers cannot be processed.
A toll-free 800 number for you and members to use to locate health care
providers in another Blue Plan’s area. This number is useful when you need
to refer the patient to a physician or health care facility in another location.
2. How do I submit international claims?
BlueCard Eligibility® 1-800-676-BLUE
The claim submission process for international Blue Plan
members is the same as for domestic Blue Plan members.
You should submit the claim directly to BCBSVT.
A toll-free 800 number for you to verify membership and coverage
information, and obtain pre-certification on patients from other Blue Plans.
3. How do I handle Medicare-related claims?
•When Medicare is a primary payor, submit claims to your local
Medicare intermediary. After receipt of the Remittance Advice (RA)
from Medicare, review the indicators:
•If the indicator on the RA shows that the claim was crossed-over,
Medicare has submitted the claim to the appropriate Blue Plan and
the claim is in progress. You can make claim status inquiries for
supplemental claims through BCBSVT.
•If you have any questions regarding the crossover indicator,
please contact the Medicare intermediary.
•If you have any questions regarding the crossover indicator,
please contact the Medicare intermediary.
•Do not submit Medicare-related claims to your local Blue Plan
before receiving an RA from the Medicare intermediary.
•If you are using an OCNA number on the Medicare claim,
ensure it is the correct OCNA number for the member’s
Blue Plan. Do not automatically use the OCNA number for the
local Host Plan or create an OCNA number of your own.
•Do not create alpha prefixes. For an electronic HIPAA 835
(Remittance Advice) request on Medicare-related claims, contact BCBSVT.
•If you have Other Party Liability (OPL) information, submit
this information with the Blue claim. Examples of OPL
include Workers’ Compensation and auto insurance.
•Do not send duplicate claims. First check a claim’s status by
contacting BCBSVT by phone or through the BlueExchange link.
BlueCard PPO
A national program that offers members traveling or living
outside of their Blue Cross and/or Blue Shield Plan’s area the
PPO level of benefits when they obtain services from a physician
or hospital designated as a BlueCard PPO provider.
BlueCard PPO Member
Carries an ID card with this identifier on it.
Only members with this identifier can access
the benefits of the BlueCard PPO.
BlueCard Doctor & Hospital Finder Web Site
www.bcbs.com/healthtravel/finder.html
A Web site you can use to locate health care providers in another
Blue Cross and/or Blue Shield Plan’s area—www.bcbs.com/
healthtravel/finder.html. This is useful when you need to refer the
patient to a physician or healthcare facility in another location. If
you find that any information about you, as a provider, is incorrect
on the Web site, please contact (local Plan’s contact info).
BlueCard Worldwide®
Glossary of BlueCard Program Terms
A program that allows Blue members traveling or living
abroad to receive nearly cashless access to covered inpatient
hospital care, as well as access to outpatient hospital care and
professional services from health care providers worldwide. The
program also allows members of foreign Blue Cross and/or Blue
Plans to access domestic (U.S.) Blue provider networks.
Alpha Prefix
Consumer Directed Health Care/Health Plans (CDHC/CDHP)
Three characters preceding the subscriber identification number
on the Blue Plan ID cards. The alpha prefix identifies the member’s
Blue Plan or national account and is required for routing claims.
Consumer Directed Health Care (CDHC) is a broad umbrella term that refers
to a movement in the health care industry to empower members, reduce
employer costs, and change consumer health care purchasing behavior.
CDHC provides the member with additional information to make an
informed and appropriate health care decision through the use of member
support tools, provider and network information, and financial incentives.
bcbs.com
Blue Cross and Blue Shield Association’s Web site, which
contains useful information for providers.
BlueCard Access®—1-800-810-BLUE
www.bcbs.com/healthtravel/finder.html
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Coinsurance
A provision in a member’s coverage that limits the amount
of coverage by the benefit plan to a certain percentage. The
member pays any additional costs out-of-pocket.
Coordination of Benefits (COB)
Ensures that members receive full benefits and prevents double
payment for services when a member has coverage from two or
more sources. The member’s contract language gives the order
for which entity has primary responsibility for payment and
which entity has secondary responsibility for payment.
Co-payment
A specified charge that a member incurs for a specified
service at the time the service is rendered.
Deductible
BlueCard Program Quick Tips
The BlueCard Program provides a valuable service that lets you file all
claims for members from other BC and/or BS Plans with your local Plan.
Here are some key points to remember:
•Make a copy of the front and back of the member’s ID card.
•Look for the three-character alpha prefix that precedes
the member’s ID number on the ID card.
•Call BlueCard Eligibility at (800) 676-BLUE to verify the
patient’s membership and coverage or submit an electronic
HIPAA 270 transaction (eligibility) to the local Plan.
•Submit the claim to BCBSVT, P.O. Box 186, Montpelier, VT 05601.
Always include the patient’s complete identification number, which
includes the three‑character alpha prefix.
•For claims inquiries, call BCBSVT (800) 924-3494.
A flat amount the member incurs before the
insurer will make any benefit payments.
Hold Harmless
An agreement with a health care provider not to bill the member for
any difference between billed charges for covered services (excluding
coinsurance) and the amount the healthcare provider has contractually
agreed on with a Blue Plan as full payment for these services.
Medicare Crossover
The Crossover program was established to allow Medicare to
transfer Medicare Summary Notice (MSN) information directly to
a payor with Medicare’s supplemental insurance company.
Medicare Supplemental (Medigap)
Pays for expenses not covered by Medicare.
National Account
An employer group that has offices or branches in more than one
location but offers uniform coverage benefits to all of its employees.
Other Party Liability (OPL)
A cost containment program that recovers money where primary
responsibility does not exist because of another group health plan
or contractual exclusions. Includes coordination of benefits, workers’
compensation, subrogation, and no‑fault auto insurance.
Plan
Refers to any Blue Cross and/or Blue Shield Plan.
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Section 8
Blue Cross and Blue Shield of Vermont
and the Blueprint Program:
Overview:
BCBSVT required Participating Practice
Demographic/Payment Information:
BCBSVT requirements align with the final and adopted PPPM Attribution
Physician Practice Roster used by all insurers for attribution - located here
on the Blueprint WEB site:
http://dvha.vermont.gov/advisory-boards/payerimplementation-work-group - Payment Roster Template
Below is a listing of the physician practice roster data elements,
required by BCBSVT. These data elements are used by
BCBSVT to complete a demograhic reconciliation against our
provider files and ensure appropriate Blueprint set up:
•Primary Care Provider First Name
•Primary Care Provider Last Name
The Blueprint for Health program comprises Patient Center Medical Homes •Provider Credentials (MD,DO, APRN, PA)
supported by Coummunity Health Teams (CHT) and a health information
•Provider’s Primary Scope of Practice
technology infrastructure. The Patient Centered Medical Home (PCMH) is a •Primary Care or Specialist Indicator (indicate PCP, SPECIALIST or BOTH)
health care setting that facilitates partnerships between individual patients, •Provider Phone Number
their family and their personal physicians. Information technololgy
•Individual Provider NPI
tools such as patient registries, data tracking, and health information
•Provider Term Date
exchanges provide a basis for this patient centered healthcare
•Parent Organization (if FQHC, RHC, CAH,
facilitating guideline based care, reporting and healthcare modeling.
group, or hospital-owned practice)
More information is available on the Blueprint home page located at:
•Primary Care Practice Site Name (name on the door)
http://hcr.vermont.gov/blueprint
•Primary Care Practice Name
BCBSVT has also published detailed articles in our provider publication
•Practice Physical Address
Finepoints (Summer 2012, Fall 2012 and Winter 2012-2013).
•City
•State
Enrollment into the Blueprint program is done through the Department
of Vermont Health Access (DVHA) Blueprint Staff. To learn more about
•Zip Code
the Blueprint and the requirements to become a recognized National
•Practice or Group National Provider Identifier (NPI) for Payment
Committee for Quality Assurance Physician Practice Connections®
•Practice Tax ID
- Patient-Centered Medical Home™ (PPC®-PCMH™) please refer to
the Vermont Blueprint for Health Implementation Manual located
The following physician practice roster information is used to ensure
here on the Blueprint WEB site: http://hcr.vermont.gov/blueprint
appropriate communications between the PCMH and BCBSVT. More than
one person can be listed in each category (Pay-to or Reports Contact):
Blueprint Implementation Materials:
•Contact - Pay-To Last Name for Electronic
Funds Transfer (EFT)/direct deposit
Bulletin 10-19-Vermont Blueprint for Health Rules (Adopted 3/5/11)
•Contact - Pay-To First Name for Electronic
Blueprint Manual (Nov. 2010)
Funds Transfer (EFT)/direct deposit
Or contact Blueprint Staff directly. Contact information is available
•Contact - Pay-To E-mail Address
here on the Blueprint WEB site: http://hcr.vermont.gov/blueprint
•Contact - Pay-To Phone Number
•Reports Contact - Last Name (for reports, if
Blueprint Notifications and Staff Contact Information:
different than Contact - Pay-To Name)
Contact Information
•Reports Contact - First Name (for reports, if
different than Contact - Pay-To Name)
The Vermont Blueprint for Health (Blueprint) is a vision and a statewide
partnership to improve health and the health care system for Vermonters.
The Blueprint provides information, tools and support that Vermonters
with chronic conditions need to manage their own health. The Blueprint
is working to change health care to a system focused on preventing
illness and complications, rather than reacting to health emergencies.
If you are a new Blueprint practice after verification of the roster, you may
be required to sign contract amendments to include Blueprint within your
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standard contract. In addition to the contract amendments, you will be
asked to complete an electronic funds transfer (EFT)/direct deposit form
to establish your account for receipt of the monthly PPPM payments.
Blueprint Practice Payment Method based
on VCHIP/NCQA PCHM Score:
Payment for newly-scored practices will be effective on the first of the
month after the date that the Blueprint transmits NCQA PPC-PCMH
scores from the Vermont Child Health Improvement Program (“VCHIP”)
to the Payers, and will initially be based on VCHIP scores. Changes in
payment due to the subsequent receipt of NCQA scores, as well as
for practices that are being re-scored, will occur on the first of the
month after NCQA scores are received by Payers from the Blueprint.
BCBSVT generates monthly PPPM payments. There is a one month
lag in the BCBSVT Blueprint payment cycle (i.e., for a PCMH
effective October 1st first payment will be made in November).
BCBSVT will send the organization one provider payment
for all the individual practice sites (identified by tax id)
and a monthly membership attribution report. The report
contains the following summary and data elements:
Tax ID: xxxxxxxxx
Blueprint for Health Patient Centered Medical Home
Hospital Service Area: xxxx
Paid Date: xxxxxx
Incurred Date: xxxxxx
Date: xx/xx/xxxx
Vendor Name: xxxxxxxxx
Total Dollar Amount: $x,xxx.xx
Total Number of Members are: x,xxx
If the vendor reporting has multiple practices within it, each
practice’s monthly PPPM payment is sub-totaled and at the
bottom of the report will be a grand total of all practices.
Reports are sent directly to the Reports Contact
individual(s) identified on the in the PPPM Attribution
Physician Practice Roster. Reports are sent via secure e-mail.
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BCBSVT membership attribution criteria:
We utilize the Vermont Blueprint PPPM Common Attribution Algorithm for
Commecial Insurers and Medicaid - located here on the Blueprint WEB site:
http://dvha.vermont.gov/advisory-boards/
payer-implementation-work-group
Attribution Method and List of Codes - Medicaid and Commerical Insurers
Blueprint Practice membership reconciliation:
BCBSVT provides an initial membership attribution snap-shot report to
the PCMH (or designee) in accordance with the Blueprint Manual (located
here on the Blueprint WEB site: http://hcr.vermont.gov/blueprint).
The Snap-shot report contains the following summary and data elements:
Tax ID: xxxxxxxxx
Blueprint for Health Patient Centered Medical Home
Hospital Service Area: xxxx
Paid Date: xxxxxx
Incurred Date: xxxxxx
Date: xx/xx/xxxx
Vendor Name: xxxxxxxxx
Total Dollar Amount: $x,xxx.xx
Total Number of Members are: x,xxx
If the vendor reporting has multiple practices within it, each practice’s
monthly PPPM payment is sorted and sub-totaled by vendor NPI. A grand
total for all practices can be located at the top and bottom of the report.
BCBSVT line of business (LOB) and/or Employer
Group exclusions for Blueprint payment:
Note: This is information is subject to change. Please
look for provider notifications/portal notices.
•Brattleboro Retreat
•CBA Blue
•Howard Center
•University of Vermont Medical Center Employer
Group (prefixes FAH, FAO, and FAC)
•IBEW Utility
•Inter-Plan Program
•BlueCard*
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•Brattleboro Retreat
•CBA Blue
•New England Health Plan (NEHP)
•Medicomp/Medicare Supplemental (Medicare is primary)/MediGap
•Some Administrative Service Only (ASO) Groups
*BCBS members who reside in Vermont have the opportunity to
participate in the Blueprint for Health program. Those that do
choose to participate will be included in reporting and payments.
Need help Identifying BCBSVT/CBA Blue/TVHP/NEHP
Members? Click here: http://www.bcbsvt.com/export/sites/
BCBSVT/provider/resources/referenceguides/Identifying_
BCBSVT_CBA_Blue_TVHP_NEHP_Members.pdf
Blueprint Advisory Groups - Meeting
Schedules, Minutes, Agendas:
Attribution fees are paid during the three month grace period
for individuals covered through the Exchange (prefix ZII)
and are not recovered. For full details on Grace Periods see
“grace period for individuals through the Exchange”.
Blueprint Payment Implementation Work Group
•2012 Meeting Schedule
•Minutes of Meetings
•Agendas for Meetings
•PPPM Atrribution Roster Templates (3/14/2012)
•PPPM and CHT Payment Methodologies by Payer (1/16/2012)
•Attribution Method and List of Codes - Medicaid and Commercial
Insurers (1/5/2012)
•Attribution Method and List of Codes - Medicare (1/19/2011)
•Payment Implementation Work Group Members
Blueprint Payment Implementation Work Group
•Under Construction
Note: information/resources are subject to change or new
additions will be added so we encourage you to review this
information periodically to ensure you are kept informed.
Questions on the Blueprint program can be directed to your
provider relations consultant at (888) 449-0443.
Additional Blueprint Information Resources:
Additional Blueprint Information/Resources - located here on
the Blueprint WEB site: http://hcr.vermont.gove/blueprint
Blueprint Advisory Groups-Meeting
Schedules, Minutes, Agendas:
Blueprint Executive Committee
•2013 Meeting Schedule
•2012 Meeting Schedule
•Minutes of Meetings
•Agendas for Meetings
•Executive Committee Members
Blueprint Expansion Design and Evaluation Work Group
•2013 Meeting Schedule
•2012 Meeting Schedule
•Minutes of Meetings
•Agendas for Meetings
•Executive Committee Members
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Section 9
The Federal Employee Program (FEP):
Introduction
As a contracted provider/facility with BCBSVT you are
eligible to render services to Federal Employee Program
members who travel or live in Vermont.
This section is designed to describe the advantages of the program,
while providing you with information to make filing claims easy.
This section offers helpful information about:
Identifying members
Verifying eligibility
Obtaining pre-certifications/pre-authorizations
Filing claims and
Who to contact with questions
The Federal Employee Program (FEP)
Is a health care plan for government employees, retirees, and their
dependents. It provides hospital, professional provider, mental health,
substance abuse, dental and major medical coverage of medically
necessary services and supplies. BCBSVT processes claims for FEP services
rendered by Vermont providers in Vermont to FEP members. Members
with FEP coverage have ID numbers that begin with alpha prefix R.
Federal Employee Program Advantages to Providers
The Federal Employee Program allows you to conveniently submit
claims for members that receive services in the State of Vermont,
regardless of their residence. BCBSVT is your point of contact for
questions on services rendered in Vermont, including eligibility,
benefits, pre-certification, prior approval and claim status.
Member ID Cards
When an FEP member arrives at your office or facility, be sure
to ask them for a current membership identification card.
The main identifier for a (FEP) member is the alpha
prefix of R. The ID cards may also have:
•PPO in a United State logo, eligible for PPO members
•Basic written in a United State logo
Important facts concerning members IDs:
•A correct member ID number includes the
alpha prefix R followed by 8 digits.
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As a provider servicing out-of-area members, you
may find the following tips helpful:
•Ask the member for the most current ID card at every visit. Since new ID
cards may be issued to members throughout the year. This will ensure
that you have the most up-to-date information in your patients file.
•Member IDs only generate in the subscriber name
•The back of the ID card will have the member’s local plan
information; however, if you are rendering the services in
Vermont, BCBSVT will be your point of contact.
•Make copies of the front and back of the member’s ID card
and pass the key information on to your billing staff.
Remember: Member ID numbers must be reported exactly as
shown on the ID card and must not be changed or altered. Do not
add or omit any characters from the member’s ID numbers.
Sample ID Cards:
The United States logo will appear on the top right on the front of card.
*Enrollment Code*
PLAN OPTION
STANDARD OPTION (PPO)
BASIC OPTION
FEHB ENROLLMENT CODE
SELF SELF & FAMILY
104 105
111 112
Coverage and Eligibility Verification
Verifying eligibility and confirming the requirements of the
member’s policy before you provide services is essential to
ensure complete, accurate and timely claims processing.
There are two methods of verification available:
Electronic - Submit an electronic transaction via the tool located
on the provider web site at www.bcbsvt.com. Please refer
to the manual located in the section for specific details.
Phone - Call the Federal Employee Program
customer service at (800) 328-0365.
Advanced Benefit Determinations
Federal Employee Program (FEP) members are entitled to BCBSVT
reviewing and responding to “Advanced Benefit Determinations”.
This allows members and providers to submit a request in
writing asking for benefit availability for specific services and
receive a written response on coverage. Refer to section 4 Advanced Benefit Determination for further information.
Utilization Review
You should remind patients that they are responsible for obtaining
pre-certification/preauthorization for specific required services.
When the length of an inpatient hospital stay extends past the
previously approved length of stay, any additional days must be
approved. Failure to obtain approval for the additional days may
result in claims processing delays and potential payment denials.
You can do so by:
Calling the Federal Employee Program (800) 328-0365 and
ask to be transferred to the utilization review area. Or contact
the utilization review area directly at (800) 922-8778.
The BCBSVT plan may contact you directly related to clinical
information and medical records prior to treatment or for concurrent
reivew or disease management for a specific member.
Claims Filing
with only valid alpha-prefixes; claims with incorrect or missing alpha
prefixes and member identification numbers cannot be processed.
•In cases where there is more than one payer and a Blue Cross and/
or Blue Shield Plan is a primary payer, submit Other Party Liability
(OPL) information with the Blue Cross and/or Blue claim.
•Do not send duplicate claims. Sending another claim, or having your
billing agency resubmit claims automatically, actually slows down
the claims payment process and creates confusion for the member.
•Check claims status by contacting the Federal
Employee Program at (800) 328-0365.
•Through an electronic transaction via the Blue
Exchange tool on www.bcbsvt.com.
Traditional Medicare-Related Claims when FEP is secondary
When Medicare is primary payor, submit claims
to your local Medicare intermediary.
After you receive the Remittance Advice (RA) from Medicare, attach a
copy to the claim and submit on paper to BCBSVT for processing.
The FEP Program for BCBSVT is not currently
set up as automatic cross over plan.
Below is an example of how claims flow through the
Federal Employee Program. You should always submit
claims to BCBSVT (services rendered in Vermont).
You can make status inquiries for secondary claims through BCBSVT.
1. Member of Federal Employee Program receives
services from you, the provider
There are times when BCBSVT will require medical records to review
a claim. These requests will come directly from BCBSVT. Forward all
requested medical records to BCBSVT, including the cover sheet that was
provided in the request. Questions or inquiries regarding medical records
need to be directed to the Medical Services Department at (800) 9228778. Do not send medical records with a claim, unless requested by
BCBSVT. Unsolicited claim attachments may cause claim payment delays.
2. Provider submits claim to the local Blue Plan
3. BCBSVT recognizes FEP member and adjudicates claim according to
member’s benefit plan and transmits claim payment disposition
4. BCBSVT plan issues an EOB to the member and
a Remittance advice to you, the provider
5. You the provider, should follow with member on appropriate out
of pocket costs if applicable according to your remittance advice.
Following these helpful tips will improve your claim experience:
•Ask members for their current member ID card and regularly obtain new
photocopies of it (front and back). Having the current card enables you
to submit claims with the approrpriate member information (including
R alpha prefix) and avoid unnecessary claims payment delays.
•Check eligibility and benefits electronically at www.bcbsvt.com or by
calling (800) 328-0365. Be sure to provider the member’s R alpha prefix.
•Submit all Blue claims to BCBSVT, P.O. Box 186, Montpelier, VT 05601.
Be sure to include the member’s complete identification number when
you submit the claim. This includes the R alpha prefix. Submit claims
Medical Records
Coordination of Benefits (COB) Claims
Coordination of benefits (COB) refers to how we ensure members receive
full benefits and prevent double payment for services when a member
has coverage from two or more sources. The member’s contract language
explains the order for which entity has primary responsibility for payment
and which entity has secondary responsibility for payment. if you
discover the member is covered by more than one health plan, and:
•BCBSVT or any other carrier is the primary payer, submit other carrier’s
name and address with the claim to BCBSVT.
•Other non-Blue health plan is primary and BCBSVT or any other Blue
Plan is secondary, submit the claim to BCBSVT only after receiving
payment from the primary payor, including the explanation of payment
from the primary carrier.
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If you do not include the COB information with the claim, it will
result in having to investigate the claim. This investigation could
delay your payment or result in a post-payment adjustment,
which would also increase your volume of bookkeeping.
Dental Services
The FEP medical benefit coverage provides benefits for select procedures
that are identified under the Schedule of Dental Allowance and Maximum
Allowance Charges (MAC). Member’s also have the opportunity to
purchase a dental supplement. The supplement is called FEP BlueDental.
Members who have opted to purchase the FEP BlueDental
supplement will have a separate identification card. It will be
important to request the member supply both ID cards at the
time of the visit (FEP BCBSVT and FEP BlueDental). You will
want to make copies of both of the cards to keep on file.
The FEP medical dental network consists of providers who have
contracted directly with BCBSVT. The contract you hold with
BCBSVT does not include the FEP BlueDental network.
The FEP BlueDental network (for Vermont) consists of providers who
have contracted through CBA Blue. The Blue Cross and Blue Shield of
Vermont (BCBSVT) FEP contract you hold will not make you eligible to
receive benefits or be a network provider for the FEP BlueDental network.
Claims need to be submitted to the FEP program associated with the
member’s medical benefit coverage first for consideration of benefits.
For example, if you rendered the services in Vermont, you submit to
BCBSVT. If the services you rendered were in New Hampshire, you
submit to Anthem BCBS. Once the claims have processed through
the medical benefits coverage portion (you will receive your normal
remittance advice), if appropriate the claim will be forwarded on
to the FEP BlueDental network for processing. You will receive the
results of that processing directly from the FEP BlueDental.
Glossary of Federal Employee Program Terms:
Alpha Prefix
R character preceding the subscriber identification number
on the ID cards. The alpha prefix identifies the Federal
Employee Program and is required for routing claims.
www.bcbsvt.com/provider
Blue Cross and Blue Shield Association’s Web site, which
contains useful information for providers.
Doctor & Hospital Finder Web Site
http://provider.bcbs.com/
A Web site you can use to locate health care providers in another
BlueCross and/or Blue Shield Plan’s area. This is useful when you need
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to refer the patient to a physician or healthcare facility in another
location. If you find that any information about you, as a provider, is
incorrect on the Web site, please contact (local Plan’s contact info).
Enrollees (members)
All Federal Employees, Tribal Employees, and annuitants who are
eligible to enroll in the Federal Employee Health Benefits Program.
www.fepblue.org
Federal Employee Program website
Index
A
Access Standards 10
Primary Care and OBGYN Services 10
Specialty Care Services 10
After Hours Phone Coverage 9
Availability of Network Practitioners
Frequency of Geographic Access Analysis 11
Frequency of Linguistic and Cultural Needs and
Preferences Analysis 11
Geographic Access 11
Linguistic and Cultural Needs and Preferences 11
Network Availability Standards 11
Performance Goals 11
Travel Time Specification 11
B
BCBSVT/TVHP Special Health Programs 31–33
BlueHealth Solutions 32
Diabetes Education 32
Hospice 32
Better Beginnings 31
BlueCard 2, 53–62, 63–66, 67–69
BlueCard Program Quick Tips 62
Claim Filing 56
How Does the BlueCard Program Work? 53
How to Identify Members 53
Alpha Prefix 54
Consumer Directed Health Care and Health Care Debit
Cards 54
Coverage and Eligibility Verification 56
Member ID Cards 53
Sample combined Health Care Debit Card and
Member ID Card 55
Sample ID Cards 54–56
Utilization Review 56
Introduction 53, 63, 67
What is the BlueCard Program? 53, 63, 67
Accounts Exempt from the BlueCard Program 53
Advantages to Providers 53
Definition 53
Blue Cross and Blue Shield of Vermont
Privacy Practices 16
Blue Cross and Blue Shield of Vermont Website 17
BlueHealth Solutions 32–33
C
CBA Blue 2
Claim Filing 56
Adjustments 59
Appeals 59
Calls from Members and Others with Claim
Questions 59
Claim Payment 59
Claim Status Inquiry 59
Coordination of Benefits (COB) Claims 59
Eligibility Verification 58
Example of how claims flow through BlueCard 56, 64
How Claims Flow through BlueCard 56
How to recognize Medicare Advantage Members 58
International Claims 59
Medical Records 59
Medicare Advantage Claims Submission 58
Medicare Advantage Overview 57, 65, 66
Providers in a Border County or Having Multiple
Contracts 59
Traditional Medicare-Related Claims 58
Types of Medicare Advantage Plans 57, 65
Claims
Attachments 38
Negative Balances 36
Specific Guidelines 41
Submission 38
Submission and Reimbursement Guidelines 41–52
Claim Specific Guidelines 41–42
Claim Check 42
Special Instructions 41
Claim Status 40
Claim Submission and Reimbursement Guidelines 41–43
Allergy 44
Anesthesia 44
Bilateral Procedures 46
Biomechanical Exam 46
BlueCard Claims 42
Breast Pumps 46
Claim Check 42
Surgical Trays 52
Claim Submission and Re-submission Information 38–44
CMS 1500 Claims Form Instructions 40
Coordination of Benefits (COB) 39
Electronic Data Interchange (EDI) Claims 38
General EDI Claim Submission Information 38
How to Avoid Paper Claim Processing Delays 38
Important Reminders Regarding Submission of the
HCFA 1500 40
Medicare Supplemental and Secondary Claim
Submission 39
Paper Claim Submission 38
Paper Remittance Advice 40
Complaint and Grievance Process 14–15
BlueCard Member Claim Appeal 15
Provider on Behalf of Member Appeal Process 14
Level 1—A First Level Provider on behalf of Member
Appeal 14
Level 2—Voluntary Second Level Appeal (not
applicable to nongroup or Catamount members)
14
Level 3—Independent External Appeal 15
Contracting 3
Co-payment 37
Credentialing 5
D
Diabetes Education 32
E
Evaluation and Management reminder 46, 47, 48
F
Federal Employee Plan (FEP) 2
Fee-for-Service 2
Frequently Asked Questions 59
BlueCard Basics 59
Claims 60
Where and how do I submit claims? 60
Identifying Members and ID Cards 60
Utilization Review 60
Verifying Eligibility and Coverage 60
G
General Claim Information 35–37
Accounting for Negative Balances 36
Balance Billing Reminders 35
BCBSVT Provider Claim Review 41
Claim Filing Limits 35
Co-payments and HealthCare Debit Cards 37
Corrected Claim 41
How to use a Healthcare Debit Card 37
Industry Standard Codes 35
Resubmission of Returned Claims 40
Take Back of Claim Payments & Overpayment
Adjustment Procedures 35, 36
Where to Find
Co-payment Information 37
Glossary of BlueCard Program Terms 61–62
Alpha Prefix 61
bcbs.com 61
BlueCard Access 61
BlueCard Doctor & Hospital Finder Web Site 61
BlueCard Eligibility 61
BlueCard PPO 61
BlueCard PPO Member 61
Coinsurance 61
Consumer Directed Health Care/Health Plans 61
Coordination of Benefits (COB) 62
Co-payment 62
Deductible 62
Hold Harmless 62
Medicare Crossover 62
Medicare Supplemental (Medigap) 62
National Account 62
Other Party Liability (OPL) 62
Plan 62
H
Health Insurance Portability and Accountability Act
(HIPAA) 15–16
Business Associates 15
Disclosure of Protected Health Information 15
Responsibilities 15
Standard Transactions 16
Hospice 32
I
Indemnity (Fee-for-Service) and Preferred Provider
Organization (PPO) 2
L
Laboratory Handling 49
Laboratory Services (self-ordered by patient): 49
Locum Tenens 49
M
Maternity 49
Medical Utilization Management 24
75
Admission Review 28
Case Management 29
Clinical Review Criteria 25
Concurrent Review 28
Discharge Planning and Discharge Outreach 28
Episodic Case Management/
Authorization of Services 29
focused inpatient utilization 24
Pre-certification of Admissions 28
Prior Approval 26
Provider Referrals to Case or Disease Management 29
Urgent Pre-Service Review 29
Utilization Review Process 25
Member Certificate Exclusions 18
Member Eligibility and Coverage Type
Verifying Membership Phone Numbers 18
Member Identification Cards 19–21
Blue Card 54. See Section 7
The Vermont Health Plan (TVHP) 20
Vermont Blue 65(formerly known as Medi-Comp) 20
Member Rights and Responsibilities 16
Mental Health and Substance Abuse Claim Appeal
(Grievance)
When You Have to Pay 15
Modifiers 49
N
New England Health Plan (NEHP) 2
Notification of Change In Provider Information 13–15
Adding a Provider to a
Group Vendor 13
Deleting a Provider From a Group Vendor 14
Provider Going on Sabbatical 13
O
Office Training and Orientation 3
Opening/Closing of Primary Care Physician Patient
Panels 11
Closing of an Open Physician Panel 11
Opening of a Closed Physician Panel 11
PCPs with closed patient panels 11
Primary Care Services 11
P
Paper Remittance Advice 40–41
Participation 4
incentives for 4
Practitioner Roles and Responsibilities 7–10
Access to Facilities and Maintenance of Records for
Audits 8
Billing of Members 8
Confidentiality and Accuracy of Member Records 8
Conscientious Objections to the Provision of
Services 7
Continuity of Care 7
Coordination of Care 7
Follow-up and Self-care 7
Open Communication 7
Primary Care Physician Coordinates Care 7
Specialty Provider Responsibilities 7
Pre-certification of Admissions
Episodic Case Management/Authorization
76
of Services 29
Provider Referrals to Case or Disease Management 29
Primary Care and OBGYN Services 10
Primary Care Physician (PCP) 7
Prior Approval/Referral Authorization 8
Provider on Behalf of Member Appeal Process 14
Provider Participation and Contracting 3
Providers
Change in Provider Information 13
Member Transfer 12
Roles and Responsibilities 7
Selection Standards 33
Provider Selection Standards 33–34
Confidentiality of Member Medical Records 34
Medical Record Standards, Confidentiality
Requirements and Performance Goals 33
Office Site Review 34
Performance Goals and Measurement 34
Provider Appeal Rights 33
Recredentialing Procedures 33
Retrieval and Retention of Member Medical
Records 34
Q
Quality Improvement (QI) Program 30–31
HEDIS and Quality Data Gathering 31
Quality Improvement Committees 31
R
Reimbursement 6
capitation 6
fee for service 6
Reporting of
Fraudulent Activity 9
Riders 3
T
Tax Identification Number 13
The Vermont Health Plan (TVHP) 2
U
Utilization Management Denial Notices: Reviewer
Availability 14
V
Vermont Blue 65 Medicare Supplemental Insurance
(formerly Medi-Comp) 2
Vermont Health Partnership (VHP) 3
W
Waivers 9
When to Collect a Co-payment
Member Responsibility for Co-payment 38
Physician’s Office 37
Revised 9/19/16
77