Illinois Public Health Association: Online Tips for Your Practice

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1 Illinois Public Health Association: Online Tips for Your Practice Presented by: Roy Pyers & J ne Kanady BCBSIL Provider Network Consultants A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 Provider Network Consultants As a team, the Provider Network Consultants (PNC) support over 105,000 individual practitioners and professional provider groups throughout the state. Each PNC averages a caseload of 5,800 billing providers. July 15 2

3 Provider Network Consultant Functions Keeping You Informed Discussing BCBSIL products and services Updating you on important initiatives (e.g. ACA, ICD 10) Understanding Your Provider Contract Answering questions you have about your contract Helping you navigate through the provider manual, when needed Helping You Locate Resources Directing you to the appropriate department Helping you locate forms and tutorials Visiting Your Office When you need us To address special needs and concerns Complex Claim Situations When they cannot otherwise be resolved by Customer Service Large volume (100+) claim adjustments July 15 3

4 Important Provider Resources BlueReview ICD 10 Tutorials/User Guides Update Your Information Blue Access for Providers SM Forms July 15 4

5 BCBSIL Provider Inquiry Channels Preferred Web Vendors Real time eligibility and benefits Up to the minute claim status details Printable Results Access to submit preauthorization and claim reconsideration requests online (iexchange) * Electronic Refund Management* IVR Phone System Real time eligibility and benefits Confirmation numbers assigned to benefit quotes Options to have benefit quotes faxed to your office Claim status will be offered exclusively online through the Availity Claim Research Tool and other preferred Web tool Customer Advocate (CA) Claim Adjustments Eligibility and benefit verifications unable to be quoted by a preferred web vendor or the IVR Inquiries pertaining to specific CPT codes Procedure and diagnosis policy exclusions Note: BCBSIL preferred Web vendors include Availity, ecare, Passport and Nebo July 15 Provider ebusiness Services * Only available through availity.com. 2

6 Availity Eligibility Patient Information Subscriber Information Group Number & Name Coverage Status Current Effective Date Type of Coverage Pre existing Completion Date Other Insurance Information July 15 6

7 Availity Benefit Information Copayment Co insurance Limitations Maximums Coverage Level (family vs individual) Deductible* Out of Pocket* Preauthorization Requirements * Includes original amounts and remaining balances July 15 7

8 Speak to an Agent July 15 Provider ebusiness Services 8 9

9 Speak to an Agent 1 Eligibility & Benefits Inquiry 2 Eligibility & Benefits Return July 15 Provider ebusiness Services 9 10

10 Speak to an Agent Active for medical eligibility & benefit inquiries ONLY Displayed ONLY when benefits not returned Offered ONLY when Provider Customer Service is the benefit contact entity (i.e., no labor funds or vendor carve outs) Provided ONLY during CA business hours Reference ID is ONLY valid for same patient / same day Enables quick transition from web to phone This is a NEW special feature saying to our providers for trying on line first. July 15 Provider ebusiness Services 10 11

11 Affordable Care Act Key Features: Ends Pre Existing Condition Exclusions Keeps Young Adults Covered Ends Arbitrary Withdrawals of Insurance Coverage Guarantees Your Right to Appeal July 15 11

12 Affordable Care Act Key Features: Ends Lifetime Limits on Coverage Reviews Premium Increases Helps You Get the Most from Your Premium Dollars July 15 12

13 Individual and small group plans sold on and off the Marketplace websites have four coverage levels defined by cost and value: BRONZE SILVER GOLD PLATINUM Lowest Premium Mid cost Premium Higher Premium Highest Premium Plan pays about 60% of covered medical services Plan pays about 70% of covered medical services Plan pays about 80% of covered medical services Plan pays about 90% of covered medical services July 15 13

14 Affordable Care Act Key Features: Covers Preventive Care at No Cost to You Choice of Doctor from Your Network Removes Insurance Company Barriers to Emergency Services July 15 14

15 Affordable Care Act Essential Benefits Hospitalization Emergency services Laboratory services Maternity and newborn care Mental health and substance abuse disorder services* Prescription drugs Habilitative and rehabilitative services and devices Preventive and wellness services and chronic disease management Ambulatory patient services Pediatric services, including oral and vision care * Including behavioral health treatment July 15 15

16 Affordable Care Act Preventative Services Examples Adult Colorectal cancer screenings Immunization vaccines STI Counseling Women Contraceptives Screening Mammograms Well Woman Visits For additional information, visit preventive care benefits Children Immunizations Obesity Screening and Counseling Vision Screening July 15 16

17 iexchange Online option to submit BCBSIL preauthorization requests (when required) Availity offers a Single Sign on feature Non Availity users can access the tool via the BCBSIL provider website: bcbsil.com/provider Not applicable when preauthorization is managed by an outside entity (i.e., vendor, labor fund, etc.) To determine if preauthorization is required, obtain a benefit quote prior to rendering services. July 15 17

18 iexchange Note: Pended requests should be finalized within 2 3 days July 15 18

19 Availity Claim Research Tool Exclusive BCBSIL claim status feature Carrier Specific Recommend over basic claim status Equivalent of an Explanation of Benefits Detailed ineligible reason descriptions Reliable accuracy July

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22 The Claim Inquiry Resolution & Electronic Refund Management Onboarding Form After submitting the form, users will receive an validation from HCSC Refund Management. After selecting the validation link included in the , users will gain access to the portal. April

23 The Claim Inquiry Resolution Medicare / Other Ins EOB Duplicate Denial Fee Schedule / Pricing Inquiry* * Fee Schedule / Pricing Inquiry is only applicable for professional providers. Federal Additional Information Eligibility Corrected Claim** ** Electronic claim submitters can also resubmit corrected / replacement claims through their clearinghouse. Preauthorization Professional providers should utilize Billing Frequency Code 7 Institutional providers should enter the number 7 as the third digit of the Bill Type July 15 23

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25 Electronic Refund Management Centralize your internal refund management process Accessible via Availity or RealMed Electronic refund notifications Inquire, Dispute or Appeal Supporting documentation upload Multiple payment options Unsolicited refund capability Check Alerts April

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27 Availity Remittance Viewer Who Can Use It Providers and billing services Users registered to receive 835 Electronic Remittance Advice (ERA) and/or Electronic Payment Summaries (EPS)* Availity Clearinghouse Practice Management System What Does It Do Retrieves missing remittances Pulls duplicate check EOBs Functions Multiple search options Check number / Trace number Patient Claim Information Printable Results * Commonly referred to as Explanation of Benefits (EOB) July 15 27

28 Availity Remittance Viewer July 15 28

29 Tip Sheets & Complimentary Webinars Tip Sheets From the Education & Reference Center tab, select Provider Tools Webinars From the Education & Reference Center tab, select Workshops/Webinars Current Topics Include: Back to Basics: Availity 101 Availity Claim Research Tool iexchange Remittance Viewer Customized training is also available! July 15 29

30 Questions July 15 30