New Clinical Edit Rules

Endoscopy Services

On December 7, 2018, Blue Cross and Blue Shield of Kansas City (Blue KC) implemented a new clinical edit rule for endoscopy services.

Historically, Blue KC manually priced endoscopy codes when billed on multiple lines via provider claim inquiries. These new enhancements have automated that process, and thus providers are no longer required to submit records or inquiries for these services.

Time-Based Therapy Services

Effective January 1, 2019, Blue KC will implement a new clinical edit rule for time-based therapy services. We are updating our pricing rules to be in better alignment with The Centers for Medicare and Medicaid Services (CMS) methodology.

Official instructions regarding this change can be viewed here.

If you have any questions related to these changes, please contact your designated Provider Service Representative or the Blue KC Provider Hotline at 816-395-3929.

New Pricing Guidelines on Infusion Therapy

On January 1, 2019, Blue KC implemented new pricing guidelines to the SH and SJ modifiers.

When multiple drugs are administered, use modifiers SH or SJ as follows:

• SH identifies the second concurrently administered infusion therapy; will reimburse at 50% of the allowable.
• SJ identifies the third or more concurrently administered infusion therapy; will price at 25% of the allowable.

These reimbursement changes address industry standards, and help our provider network better serve our members.

Should you have questions about this change, please contact your Provider Relations Representative or the Blue KC Provider Hotline at 816-395-3929.

Smoking Cessation

Smoking Cessation is the process of discontinuing tobacco smoking or tobacco use by a nicotine-dependent individual.

For all Blue KC plans that are required to meet the Affordable Care Act (ACA) preventive care requirements, tobacco cessation services are covered at no cost to members when received from an in-network provider.

For more information, please click here.

New Directions ABA Medical Policy/Coverage Criteria Update

The New Directions Applied Behavior Analysis (ABA) Medical Policy has been revised effective January 1, 2019.

The new version includes:

• New definitions of functional assessments, functional behavior assessments, standardized assessments, non-standardized assessments, and custodial care.
• Emphasis on member progress over time and intensity of treatment.
• Parent training requirements for monitoring data on parent progress with incorporating treatment techniques in the home and community.
• More specific transition planning requirements.
• Parameters on telehealth for ABA.
• Corrections for spelling errors, abbreviations, and grammar were made and additional references were included.

Noticeable difference include:

1. Comprehensive Diagnostic Evaluation changes:
   • None
2. Initial and Continued Stay Criteria Changes:
   • Focus on active Autism Spectrum Disorder (ASD) core symptoms now includes a specific reference to substantial deficits and clinically significant aberrant behaviors.
   • Initial and ongoing assessments are now required to utilize direct observation of the member.
   • Treatment plan goals have been clarified to include measured baseline of targeted goal, objective present level of behavior, and mastery criteria.
   • Telehealth/telemedicine parameters have been included to allow for supervision and parent training activities through this modality and to exclude direct member care through telehealth.
   • Caregiver participation now indicates that not meeting this criteria will require the treater to supply clinical rationale to address generalization of skills in the community and home setting. Caregiver training requirements have been modified to include the need for data gathering and analysis of caregivers’ ability to implement ABA techniques while the member is in the home and community.
3. Continue Stay Criteria changes:
   • Transition of care requirements now include specific tasks to be completed during each review period.

Should you have questions related to these changes or to request a copy of the New Directions ABA Medical Policy, please email Tiara Bonds, Behavioral Health Provider Relations Representative, at Tiara.Bonds@BlueKC.com.

Corrected Electronic Claims

We are pleased to announce that Blue KC now accepts corrected electronic claims for professional and institutional services. Please note that effective February 1, 2019, Blue KC will only accept corrected claims electronically for all services.

Blue KC expects the original claim submission to be accurate and fully reflect all information gathered during the initial patient encounter. However, when a corrected claim is necessary, please note the requirements and information listed below.

Claim corrections submitted without the appropriate data elements will deny and the original claim will not be adjusted. The following data elements must be provided on the corrected electronic claim:

Name of Data Element	837P or 837I Loop and Data Element	Data Element Information
Claim Frequency Type Code	2300 / CLM05 - 3	7 (Replacement of a Prior Claim) 8 (Void of a Prior Claim)
Payer Claim Control Number Number Qualifier (Original Reference Number Qualifier)	2300 / REF01	F8
Payer Claim Control Number (Original Claim Number)	2300 / REF02	The original BCBSKC assigned claim number.
Claim Note Reference	2300 / NTE01	ADD (Additional Information)
Claim Note Text	2300 / NTE02	Free-form text field (80 characters) to provide a description of correction.

Please use the following listing to determine when it is necessary to submit a corrected electronic claim:

Submit a corrected claim for the following:	Do not submit a corrected eletronic claim for the following (use a claim inquiry via the Blue KC Provider Portal):
COB - Original claim was denied for other carrier info. Send a corrected claim with the necessary COB data elements.	Claims that have been denied for medical necessity.
Changes related to date of service, CPT, HCPCS, DX code, modifiers, revenue code, type of bill or units. These are just some examples of changes that could be made.	Claims that have been denied for investigational or experimental services.
Original claim was denied for additional information, such as: NDC code, CPT or HCPCS description (NOC code). Send corrected claim with full code description in the Claim Note Text.	Claims with services that have been bundled or denied inclusive of another service.
Original claim for DME, Clinical Lab or Specialty Pharmacy denied for no referring physician. Send corrected claim with the referring physician info.	Claims that have been denied for lack of information request for additional clinical documentation (office notes, surgical notes, reports, etc.).

How will Blue KC handle my corrected electronic claim (837P or 837I)?

Blue KC Line of Business	Original Claim	Corrected Claim
Regular (local) Business	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on the same remittance advice.
Federal Employee (FEP)	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on the same remittance advice.
BlueCard (ITS)	Claim will be voided	Claim will be processed. There will be a recoup on the original claim and the corrected claim will be processed and paid if applicable on different remittance advices. Because these claims are going to the members' Home Plan, please allow 30 days for the corrected claim to process.

NOTE: Claims returned or rejected should not be submitted as corrected claims. Only claims that have completed adjudication should be submitted as corrected. When sending a corrected electronic claim you must re-send the claim in its entirety including the corrections.

REMINDER: Effective February 1, 2019, Blue KC will only accept corrected claims electronically. Providers can do one of the following:

1. Send a Corrected Electronic Professional Claims (837P).
2. Complete corrected claim on Blue KC’s Provider Portal.

How will Blue KC handle paper corrected claim inquiries after February 1, 2019?

Paper corrected claim inquiries will be returned to the provider with a communication directing the provider to file an electronic adjustment.

What happens when a corrected claim is completed on the Blue KC Provider Portal after February 1, 2019?

Corrected claim inquiries completed within the Blue KC Provider Portal are imaged directly into Perceptive and are processed. The corrected claim will be processed and paid if applicable on the same remittance advice.

For more information on electronic corrected claims and other claim filing tips, please contact your designated Provider Relations Representative or the Blue KC Provider Hotline at 816-395-3929.

2018 Medicare Advantage PPO Network Sharing

What is BCBS Medicare Advantage (MA) PPO Network sharing?

All Blue MA PPO Plans participate in reciprocal network sharing. This network sharing allows all Blue MA PPO members to obtain in-network benefits when traveling or living in the service area of any other Blue MA PPO Plan as long as the member sees a contracted MA PPO provider.

What does the BCBS MA PPO Network sharing mean to me?

If you are a contracted MA PPO provider with Blue Cross and Blue Shield of Kansas City (Blue KC) and you see MA PPO members from other Blue Plans, these members will be extended the same contractual access to care and will be reimbursed in accordance with your negotiated rate with your Blue KC contract. These members will receive in-network benefits in accordance with their member contract.

If you are not a contracted MA PPO provider with Blue KC and you provide services for any Blue MA members, you will receive the Medicare allowed amount for covered services. For urgent or emergency care, you will be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.

PLEASE NOTE: The information on this notice applies to MA BlueCard host membership only.

How do I recognize an out-of-area member from one of these Plans participating in the BCBS MA PPO network sharing?

The “MA” in the suitcase indicates a member who is covered under the MA PPO network sharing program. Members have been asked not to show their standard Medicare ID card when receiving services; instead, members should provide their Blue Cross and/or Blue Shield member ID.

Do I have to provide services to MA PPO members from these other Blue Plans?

If you are a contracted MA provider with Blue KC, you should provide the same access to care as you do for Blue KC MA PPO members. You can expect to receive the same contracted rates for such services.

If you are not a MA contracted provider, you may see Blue MA members but you are not required to do so. Should you decide to provide services to Blue MA members, you will be reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and under the member’s out-of-network benefits. For urgent or emergency care, you will be reimbursed at the in-network benefit level.

What if my practice is closed to new local Blue MA PPO members?

If your practice is closed to new local Blue MA PPO members, you do not have to provide care for Blue MA PPO out-of-area members. The same contractual arrangements apply to these out-of-area network sharing members as your local MA PPO members.

How do I verify benefits and eligibility?

Please submit a real-time eligibility request (270) and Blue KC will send you a real-time response (271) with the benefit and eligibility information for the member.

Call BlueCard Eligibility at 1.800.676.BLUE (2583) and provide the member’s prefix located on the ID card.

You may also submit electronic eligibility requests for Blue members, by following these three easy steps:

• Log in to Providers.BlueKC.com.
• Follow the link to verify member eligibility by selecting "Claims/Eligibility".
• Next, select "Eligibility Access".
• Submit your request.

If you experience difficulty obtaining eligibility information, please record the prefix and report it to Blue KC at 816-395-3929.

Where do I submit the claim?

You should submit the claim to Blue KC under your current billing practices. Do not bill Medicare directly for any services rendered to a MA member.

What will I be paid for providing services to these out-of-area MA PPO network sharing members?

If you are a MA PPO contracted provider with Blue KC, benefits will be based on your contracted MA PPO rate for providing covered services to MA PPO members from any MA PPO Plan. Once you submit the MA claim, Blue KC will work with the other Plan to determine benefits and send you the payment.

What will I be paid for providing services to other MA out-of-area members not participating in the MA PPO Network Sharing?

When you provide covered services to other MA PPO out-of-area members not participating in network sharing, benefits will be based on the Medicare allowed amount. Once you submit the MA claim, Blue KC will send you the payment. However, these services will be paid under the member’s out-of-network benefits unless for urgent or emergency care.

What is the member cost sharing level and co-payments?

MA PPO members who see MA PPO contracted providers in Blue KC will pay the same cost sharing level (in-network cost sharing) they would pay if they received covered benefits from any MA PPO in-network. You may collect the co-payment amounts from the member at the time of service.

May I balance bill the member the difference in my charge and the allowance?

No, you may not balance bill the member for this difference. Members may be balance billed for any deductibles, co-insurance and/or co-pays.

What if I disagree with the reimbursement amount I received?

If there is a question concerning the reimbursement amount, contact Blue KC at 816-395-3929.

Who do I contact if I have a question about MA PPO network sharing?

If you have any questions regarding the MA program or products, contact Blue KC at 800-320-9550.

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