Thursday, 29 September 2016

Medicare Program Integrity Manual - Definitions part 1

Below is a list of terms commonly used in the Medicare enrollment process:

Accredited provider/supplier means a supplier that has been accredited by a CMS-designated accreditation organization.

Advanced diagnostic imaging service means any of the following diagnostic services:
(i) Magnetic Resonance Imaging (MRI).
(ii) Computed Tomography (CT).
(iii) Nuclear Medicine.
(iv) Positron Emission Tomography (PET).

Applicant means the individual (practitioner/supplier) or organization who is seeking enrollment into the Medicare program.

Approve/Approval means the enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges.

Authorized official means an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

Billing agency means an entity that furnishes billing and collection services on behalf of a provider or supplier. A billing agency is not enrolled in the Medicare program. A billing agency submits claims to Medicare in the name and billing number of the provider or supplier that furnished the service or services. In order to receive payment directly from Medicare on behalf of a provider or supplier, a billing agency must meet the conditions described in § 1842(b)(6)(D) of the Social Security Act. (For further information, see CMS Publication 100-04, chapter 1, section 30.2.4.)

Change in majority ownership occurs when an individual or organization acquires more than a 50 percent direct ownership interest in a home health agency (HHA) during the 36 months following the HHA’s initial enrollment into the Medicare program or the 36 months following the HHA’s most recent change in majority ownership (including asset sales, stock transfers, mergers, or consolidations). This includes an individual or organization that acquires majority ownership in an HHA through the cumulative effect of asset sales, stock transfers, consolidations, or mergers during the 36-month period after Medicare billing privileges are conveyed or the 36-month period following the HHA’s most recent change in majority ownership.

Change of ownership (CHOW) is defined in 42 CFR §489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the provider corporation does not constitute a change of ownership.

CMS-approved accreditation organization means an accreditation organization designated by CMS to perform the accreditation functions specified.

Deactivate means that the provider or supplier’s billing privileges were stopped, but can be restored upon the submission of updated information.

Delegated official means an individual who is delegated by the “Authorized Official” the authority to report changes and updates to the provider/supplier’s enrollment record. The delegated official must be an individual with an ownership or control interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 managing employee of, the provider or supplier.

Deny/Denial means the enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges.

Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.

Enrollment application means a paper CMS-855 enrollment application or the equivalent electronic enrollment process approved by the Office of Management and Budget (OMB).

Final adverse action means one or more of the following actions:
(i) A Medicare-imposed revocation of any Medicare billing privileges;
(ii) Suspension or revocation of a license to provide health care by any State licensing authority;
(iii) Revocation or suspension by an accreditation organization;
(iv) A conviction of a Federal or State felony offense (as defined in §424.535(a)(3)(i)) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or
(v) An exclusion or debarment from participation in a Federal or State health care program.

Wednesday, 28 September 2016

Medicare Program Integrity Manual - Introduction to Provider Enrollment

This chapter specifies the resources and procedures Medicare fee-for-service contractors must use to establish and maintain provider and supplier enrollment in the Medicare program. These procedures apply to carriers, fiscal intermediaries, Medicare administrative contractors and the National Supplier Clearinghouse (NSC), unless contract specifications state otherwise.

No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider and supplier enroll with the appropriate Medicare fee-for-service contractor.

Sunday, 25 September 2016

BCBS insurance payor id

State Payer ID Phone Number Website
Alabama AL 00580 800.492.8872
Alaska AK 00822 800.722.4714
Arizona AZ 53589 800.232.2345
Arkansas AR 00181 800.827.4814
California CA BC001 800.444.2726
Colorado CO 00072 877.833.5742
Connecticut CT 00103 800.922.3242
Delaware DE 005HK 800.633.2563
Florida FL 59201 800.727.2227
Georgia GA GA512 888.883.2720
Hawaii HI 99500 800.377.4672
Idaho ID 00820 866-227-0913
Illinois IL 00002 800.972.8088
Indiana IN 00715 800.470.9630
Iowa IA 00234 800.526.8995
Kansas KS 00031 800.432.3587
Kentucky KY 00660 800.470.9630
Louisiana LA 23738 225.291.4334
Maine ME 20180 207.822.8385
Maryland MD 00690 800.842.5975
Massachusetts MA 64222 800.882.2060
Michigan MI 77710 800.542.0945
Minnesota MN 00956 800.262.0820
Mississippi MS 00730
Missouri MO 00012 888.571.9054
Montana MT 00357 800.447.7828
Nebraska NE 00260 800.821.4787
Nevada NV 00265 800.992.6907
New Hampshire NH 10770 603.695.7000
New Jersey NJ 22099 800.624.1110
New Mexico NM 00290 800.835.8699
New York NY 00808 800.920.8889
North Carolina NC 05536 800.214.4844
North Dakota ND 00250 800.368.2312
Ohio OH 00834 800.470.9630
Oklahoma OK 00046 800.496.5774
Oregon OR 00850 503.225.5221
Pennsylvania PA 86500 800.992.0246
Rhode Island RI 00870 800.230.9050
South Carolina SC 57028 800.868.2505
South Dakota SD 88848 800.700.9137
Tennessee TN 00890 800.468.9736
Texas TX 00021 800.451.0287
Utah UT 00152 800.624.6519
Vermont VT 00915 800.924.3494
Virginia VA 00923 800.533.1120
Washington WA 00430
West Virginia WV 00943 800.543.7822
Wisconsin WI 09500 262.523.4782
Wyoming WY 00460 800.442.2376

Six steps in Credentialing process

Credentialing Program

Participating providers are expected to cooperate with quality-of-care policies and procedures. An integral component of quality of care is the credentialing of participating providers. This process consists of two parts: credentialing and recredentialing.

Credentialing Process

Credentialing consists of an initial full review of a provider’s credentials at the time of application to our networks.

1. If a provider applies for participation in any of our networks, credentialing is required before being approved for participation. A Louisiana Standardized Credentialing Application (LSCA) and provider agreement are forwarded to the provider upon receipt of the request for  participation in our networks. This form can be found on our website at >Forms for Providers or Credentialing.

2. The form and agreement are completed by the provider and submitted to Blue Cross for approval.

3. Upon receipt of the completed LSCA, credentialing staff verify the provider’s credentials
including, but not limited to, state license, professional malpractice liability insurance, State CDS Certificate, etc., according to the Plan’s policies and procedures and Utilization Review Accreditation Committee (URAC) standards.

4. Blue Cross staff and the Credentialing Committee, review the provider’s credentials to ascertain compliance with the following credentials criteria. All participating providers must maintain this criteria on an ongoing basis:

• Unrestricted license to practice medicine in Louisiana as required by state law
• Agreement to participate in the Blue Cross networks
• Professional liability insurance that meets required amounts
• Malpractice claims history that is not suggestive of a significant quality of care problem
• Appropriate coverage/access provided when unavailable on holidays, nights, weekends and other off hours
• Absence of patterns of behavior to suggest quality of care concerns
• Utilization review pattern consistent with peers and congruent with needs of managed care
• No sanctions by either Medicaid or Medicare
• No disciplinary actions
• No convictions of a felony or instances where a provider committed acts of moral turpitude
• No current drug or alcohol abuse

5. Based upon compliance with the criteria, Blue Cross staff will recommend to the Credentialing Committee that a provider be approved or denied participation in our networks.

6. The Credentialing Committee, comprised of network practitioners, will make a final recommendation of approval or denial of a provider’s application.

Tuesday, 20 September 2016

Locum Tenes Concept

Locum Tenens

A locum tenens is a physician who is hired to temporarily replace another physician. The usual physician may be absent for reasons such as illness, pregnancy, vacation or continuing medical education. The usual physician identifies the reported services as locum tenens physician services by entering code Modifier Q6 (service furnished by a locum tenens physician) after the procedure code on the CMS-1500 claim form. Blue Cross follows the CMS locum tenens billing requirements, which can be found at

Non-participating Providers

Non-participating providers do not have a contract with Blue Cross and Blue Shield of Louisiana, HMO Louisiana, Inc. network, or any other Blue Cross and Blue Shield plan. These providers are not in our networks. We have no fee arrangements with them. We establish an allowable charge for covered services rendered by non-participating providers. We use this allowable charge to determine what to pay

for a member’s covered services when a member receives care from a non-participating provider. The member will receive a lower level of benefit because he did not receive care from a network provider.
Additionally, a 30 percent penalty may apply when the non-participating provider is a hospital.
Members usually pay significant costs when using non-participating providers. This is because the amounts that providers charge for covered services are usually higher than the fees that are accepted by participating and HMO Louisiana providers. In addition, participating and HMO Louisiana providers waive the difference between the actual billed charge for covered services and the allowable charge, while non-participating providers do not. The member will pay the amounts shown in the “Non-Network” column on their schedule of benefits, and the provider may balance bill the member for all amounts not paid by Blue Cross or HMO Louisiana.

Please note: The member’s policy is an agreement between the member and Blue Cross or HMO Louisiana only. Providers cannot waive the member’s cost sharing obligations, such as deductibles, coinsurance (including out-of-network coinsurance differentials), penalties or the balance of the bill.
A claim that is filed that includes any amounts the provider waives may be a fraudulent claim because it includes amounts that the member is not being charged, and will be reduced by the total amount waived.

PPO and HMO Point of Service Members

When a member receives covered services from a non-participating hospital, the benefits that Blue Cross will pay under the member’s benefit plan will be reduced by 30 percent. This penalty is the member’s responsibility.

The member may also be responsible for higher copayments, coinsurances and deductibles when receiving services from non-participating providers.

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