BlueSpeak Newsletter

Opioid Initiatives

As you may know, our nation’s opioid epidemic is widespread, and continues to infiltrate our communities, workplaces, and lives. According to the Centers for Disease Control and Prevention (CDC), drug overdoses are now the number one cause of accidental death in the United States. Prescription opioid overdoses kill approximately 46 people every day and total opioid overdoses kill an estimated 130 people every day. In the Midwest, opioid overdoses increased by 70 percent from July 2016 through September 2017.

Blue Cross and Blue Shield of Kansas City (Blue KC) is committed to addressing the opioid crisis by establishing initiatives to identify problem prescribers and over utilizing members, developing programs to promote patient safety and pain management and implementing benefit changes as necessary. As a result, Blue KC is reaching out to provider partners with resources to help guide interactions with affected patients.

To help address this crisis, Blue KC has developed a three-tiered public health approach, including:

  • Prevention: Our Blue Opioid Management Program functions similar to a Prescription Drug Monitoring Program (PDMP). The PDMP calculates (cumulative/total/other) opioid use measured by Morphine Milligram Equivalents (MME) scores. The tool gives providers better visibility into a member’s opioid use for the purpose of tailoring treatment plans in accordance with best practices. Utilization of this tool has the potential to decrease the number of opioid prescriptions written, decrease treatment durations and decrease total MME scores.
    • To access the Blue Opioid Management Program Tool, log into the Blue KC provider portal by visiting Providers.BlueKC.com. Please note, your office administrator may have to provide you with permissions to access the tool.
  • Treatment: Medication-assisted treatment (MAT) for opioid use disorder treatment can be prescribed without needing prior authorization from Blue KC. In addition, we are working to expand our MAT provider network and initiating a pilot project around MAT prescribing through the Emergency Department.
  • Harm Reduction: We will continue to grow and expand our Blue Opioid Management Program. We are actively exploring opportunities for community connection and collaboration around harm reduction. We trust you will find the attached materials useful. We draw your attention to the CDC opioid-prescribing guidelines we will reference as standard-of-care in making clinical determinations.

If you or your office have questions about Blue KC’s Blue Opioid Management Program or any of the provided materials, please contact your designated Provider Relations Representative or the Provider Hotline at 816-395-3929.

Farewell Provider Office Guide (POG), Hello Provider Reference Guide (PRG)!

Blue Cross and Blue Shield of Kansas City (Blue KC) is excited to announce that we are revamping our Provider Office Guide (POG)! Coming later this year, Blue KC’s POG will be revamped and renamed as the Provider Reference Guide (PRG).

With simpler navigation, the PRG will be more interactive and easier to use. It will still be a comprehensive reference manual designed to assist you and your office staff by offering the information necessary to effectively understand and administer Blue KC insurance products and services.

We’ll be excited to share more information in the coming months. In the meantime, you can find the current version of the POG by clicking here.

For more information, please contact your designated Provider Relations Representative.

Find Billing Help Online - Provider Payment Policies Are Available on the Provider Portal

On July 1, 2019, Blue Cross and Blue Shield of Kansas City (Blue KC) introduced provider payment policies to Blue KC’s provider portal. They can be found on the landing page at Providers.BlueKC.com. Additional policies will be added quarterly, with revisions made to previous policies as needed.

These policies have been written to provide guidance on payment methodologies as they pertain to submitted claims. The policies follow standard industry recommendations from sources such as the Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT), the American Medical Association (AMA) and other professional organizations and societies. National Correct Coding Initiative (NCCI) editing is followed when applicable.

Coverage of any service is determined by the date of service, a member’s eligibility and benefit limits for the service or services rendered, all terms of the Provider Service Agreement and other standards of coding rules and guidelines. Final payment is subject to the application of claims adjudication and edits common to the industry.

We value and appreciate you as our partner in providing quality care. If you have questions on how to locate the policies, please contact the Blue KC Provider Hotline at 816-395-3929.

Claims Handling for Medicare Crossover Claims

Blue Cross Blue Shield (BCBS) Plans are required to process Medicare crossover claims for services covered under Medigap and Medicare Supplemental through the Centers for Medicare and Medicaid Services (CMS). The crossover process automatically submits Medicare claims to Blue Cross and Blue Shield of Kansas City (Blue KC) to eliminate administrative burden. Medicare crossover claims are processed in the same manner nationwide.

As a reminder, effective October 13, 2013, when a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date prior to submitting the claim to the local Plan if the charges have still not been considered by the member’s home Plan.

To help ensure timely and accurate payment processing, providers should submit services that are covered by Medicare directly to Medicare. Even if Medicare may exhaust or has exhausted, providers should continue to submit claims to Medicare to allow for the crossover process to occur and for the member’s benefit policy to be applied.

Medicare primary claims, including those with Medicare exhaust services that have crossed over and are received within 30 calendar days of the Medicare remittance date or with no Medicare remittance date, will be rejected by the local Plan.

Blue KC will reject Medicare primary claims submitted by providers with the following conditions:

  • Medicare remittance advice remark codes MA18 or N89 that Medicare crossover has occurred.
    • MA18 Alert: The claim information is also being forwarded to the member’s supplemental insurer. Send any questions regarding supplemental benefits to them.
  • Received by provider or facility’s local Plan within 30 calendar days of Medicare remittance date.
  • Received by provider or facility’s local Plan with no Medicare remittance date.
  • Received with GY modifier on some lines but not all.
    • A GY modifier is used by providers and outpatient facilities when billing to indicate that an item or service is statutorily excluded and is not covered by Medicare.

To avoid duplicate claim submissions, use the Health Care Claim Status Inquiry and Response (276/277) to verify claim and decision status prior to re-submission of electronic claims. You can also access claim status information on the Blue KC Provider Portal by visiting Providers.BlueKC.com.

Please contact your designated Provider Relations Representative with questions or concerns.

HEALTHCARE

Reminder: Annual Physical Examinations

Remember that annual physical examinations are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury and are not considered medically necessary to treat an illness or injury and are not considered to be covered services.

In addition, covered services do not include any of the following:

  1. Examinations or testing for, or in connection with, extracurricular school activities or any recreational activities; or exercise programs or equipment such as, but not limited to, bicycles or treadmills.
  2. Examinations and testing for, or in connection with, entering school, licensing, employment, insurance, adoption, immigration and naturalization or premarital blood testing.

How Utilization Management Operates

Blue Cross and Blue Shield of Kansas City’s (Blue KC) medical management staff, in collaboration with participating network physicians and providers, make decisions regarding utilization of services for Blue KC members based on the medical appropriateness of care and services.

Blue KC does not reward its medical management staff for issuing denial of coverage decisions. There is no financial incentive offered to medical management staff or network providers to make decisions that would encourage inappropriate utilization of services.

Our goal is to identify and promote appropriate usage and cost-effective healthcare resources to ensure that quality healthcare services are delivered to our members.

Contact Us

BlueSpeak is published three times a year as a service to Blue KC network providers.

Reader's comments are welcome and can be sent to Tasha James at Tasha.James@BlueKC.com.

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