Medicare, Medicare Advantage, and BCBS U...

1,336 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,336
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
13
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Medicare, Medicare Advantage, and BCBS U...

  1. 1. Medicare, Medicare Advantage, and BCBS Updates Revenue Integrity Specialist Team February 22, 2006
  2. 2. Traditional Medicare <ul><li>The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). </li></ul>
  3. 3. Traditional Medicare Plan Codes <ul><li>A20 Medicare Part A </li></ul><ul><li>A23 Medicare Part B </li></ul><ul><li>A96 Medicare Part A Railroad </li></ul><ul><li>A98 Medicare Part B Railroad </li></ul><ul><li>A55 Medicare Renal Part A </li></ul><ul><li>A56 Medicare Renal Part B </li></ul>
  4. 4. Traditional Medicare Card
  5. 5. Checking Eligibility <ul><li>Omnipath </li></ul><ul><li>a.k.a. </li></ul><ul><ul><li>BCBS Mochasoft </li></ul></ul><ul><ul><li>Florida Shared Files </li></ul></ul><ul><ul><li>MEDAAR </li></ul></ul><ul><li>Interactive Voice Response System </li></ul><ul><ul><li>1-877-908-8434 </li></ul></ul><ul><ul><li>6am-6pm </li></ul></ul><ul><ul><li>Monday through Friday </li></ul></ul>
  6. 6. Medicare Eligibility HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 07 IP-REC CN 123456789A NM SMITH IT J DB 01011920 SX M IN 00450 PN 040016 APP REAS 1 DATETIME 042502 163112 REQ SNG DISP-CODE 02 MSG UNCONDITIONAL ACCEPT CORRECT 123456789A NM IT DB SX A-ENT 070195 A-TRM 000000 B-ENT 070195 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190 DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA CURRENT 50 30 20 80 000 0 021702 040502 PRIOR 57 30 20 80 000 0 061000 061300 PARTB YR 02 DED-TBM 10000 BLD 3 YR 01 DED-TBM 00000 BLD 3 DI 1003000000 FULL-NAME SMITH.JANE.P HMO CURR ID 00000 OPT 0 ENR 000000 TERM 000000 PER 0 PRIOR ID 00000 OPT 0 ENR 000000 TERM 000000 PART A YR BLD 3 CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL YEAR 89 0056000 03 008 142 000000 000000 0000000 ESRD: CODE-1 EFF DATE CODE-2 EFF DATE PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT
  7. 7. Medicare Name Match <ul><li>Medicare requires an exact name match of the Demographic and Insurance Name </li></ul><ul><li>PBS reported over $130,000 in claims denials for name mismatch since June </li></ul><ul><li>What can you do? </li></ul><ul><ul><li>Letter </li></ul></ul><ul><ul><li>Script </li></ul></ul><ul><ul><li>Call SSA </li></ul></ul>
  8. 8. Medicare Advantage <ul><li>A Medicare program that gives you more choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (unless certain exceptions apply). Medicare Advantage Plans used to be called Medicare + Choice Plans. </li></ul><ul><li>Prescription drug coverage is a typically part of Medicare Advantage Plans. </li></ul>
  9. 9. Medicare Advantage Plan Codes <ul><li>Financial Class Code V—Sterling Option </li></ul><ul><li>S08 Arkansas Community Care Part A </li></ul><ul><li>S09 Arkansas Community Care Part B </li></ul><ul><li>S11 Humana Choice PPO Part A </li></ul><ul><li>S12 Humana Choice PPO Part B </li></ul><ul><li>Financial Class Code C—Commercial </li></ul><ul><li>Q99 Medicare Advantage </li></ul>
  10. 10. Arkansas Community Care
  11. 11. Arkansas Community Care <ul><li>Plan Codes </li></ul><ul><ul><li>S08 Part A equivalent </li></ul></ul><ul><ul><li>S09 Part B equivalent </li></ul></ul><ul><li>Financial Class Code </li></ul><ul><ul><li>V—Sterling Option </li></ul></ul><ul><li>https:// arcadianonline.arcadianhp.com/littlerock / </li></ul><ul><ul><li>See Managed Care Database for username & password </li></ul></ul>
  12. 12. Humana Choice PPO
  13. 13. Humana Choice PPO <ul><li>Medicare Advantage Plan </li></ul><ul><li>Plan Codes </li></ul><ul><ul><li>S11 Part A equivalent </li></ul></ul><ul><ul><li>S12 Part B equivalent </li></ul></ul><ul><li>http://www.humana.com/providers/home.asp </li></ul><ul><ul><li>See Managed Care Database for username & password </li></ul></ul>
  14. 14. Plan Code Q99 <ul><li>Q99—Medicare Advantage </li></ul><ul><li>Financial Class Code C—Commercial </li></ul><ul><li>It is EXTREMELY IMPORTANT to answer the MSPQ </li></ul><ul><ul><li>Special Form 2577 </li></ul></ul>
  15. 15. Q99
  16. 16. Q99
  17. 17. Q99
  18. 18. Humana Gold Plus <ul><li>Medicare Advantage Plan </li></ul><ul><li>UAMS does NOT have a contract </li></ul><ul><li>Humana Gold Plus IS DIFFERENT FROM Human Choice PPO </li></ul><ul><li>Humana Gold Choice = Q99 </li></ul>
  19. 19. Humana Gold Plus
  20. 20. Medicare Advantage Eligibility HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 07 IP-REC CN 123456789A NM SMITH IT J DB 01011920 SX M IN 00450 PN 040016 APP REAS 1 DATETIME 042502 163112 REQ SNG DISP-CODE 02 MSG UNCONDITIONAL ACCEPT CORRECT 123456789A NM IT DB SX A-ENT 070195 A-TRM 000000 B-ENT 070195 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190 DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA CURRENT 50 30 20 80 000 0 021702 040502 PRIOR 57 30 20 80 000 0 061000 061300 PARTB YR 02 DED-TBM 10000 BLD 3 YR 01 DED-TBM 00000 BLD 3 DI 1003000000 FULL-NAME SMITH.JANE.P HMO CURR ID H5700 OPT 0 ENR 010106 TERM 000000 PER 0 PRIOR ID 00000 OPT 0 ENR 000000 TERM 000000 PART A YR BLD 3 CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL YEAR 89 0056000 03 008 142 000000 000000 0000000 ESRD: CODE-1 EFF DATE CODE-2 EFF DATE PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT www.uams.edu/rist/online_resources
  21. 21. Important Tips to Remember <ul><li>Medicare Advantage can be HMO, PPO, or PFFS </li></ul><ul><ul><li>It is important to verify benefits!!!! </li></ul></ul><ul><li>These are not traditional Medicare Plans or Medicare Supplements </li></ul><ul><ul><li>Don’t COB Medicare </li></ul></ul><ul><li>These are not Medicare Part D prescription only plans </li></ul>
  22. 22. Medicare Part D—Prescription Plan <ul><li>Medicare drug plans are offered by insurance companies and other private companies approved by Medicare. There are two types of Medicare plans. </li></ul><ul><li>There are Medicare Prescription Drug Plans that add coverage to the Traditional Medicare Plan. </li></ul>
  23. 23. Medigap <ul><li>A Medicare supplement insurance policy sold by private insurance companies to fill &quot;gaps&quot; in Original Medicare Plan coverage. Except in Massachusetts, Minnesota and Wisconsin, there are 10 standardized plans labeled Plan A through Plan J. Medigap policies only work with the Original Medicare Plan. </li></ul>
  24. 24. Plan Code I30
  25. 25. Plan Code H32
  26. 26. NIA—National Imaging Associates <ul><li>Radiology Prior Authorization Service for AR Blue Cross Blue Shield </li></ul><ul><li>Procedures requiring prior authorization: </li></ul><ul><ul><li>CT Scan </li></ul></ul><ul><ul><li>MRI/MRA </li></ul></ul><ul><ul><li>Nuclear Cardiology </li></ul></ul><ul><ul><li>PET Scan </li></ul></ul>
  27. 27. NIA Continued… <ul><li>The ORDERING PHYSICIAN is responsible for obtaining prior authorization </li></ul><ul><li>Emergency room, observation, and inpatient imaging procedures do NOT require prior authorization </li></ul>
  28. 28. NIA Contact Information <ul><li>1-877-642-0722 </li></ul><ul><li>Monday-Friday 7am-7pm </li></ul><ul><li>www.radmd.com </li></ul><ul><li>AHIN </li></ul>
  29. 29. RIST Contact Information <ul><li>RIST 686-5102 </li></ul><ul><li>[email_address] </li></ul><ul><li>Holly Jones 526-7794 </li></ul><ul><li>[email_address] </li></ul>
  30. 30. Questions?

×