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Institutional Provider Manual

Entire Manual (Large PDF, 2.9MB, 288 pages, revised 2/2010)

Download the manual by sections:

Introduction (revised 3/2009)
Institutional Relations Staff (revised 3/2009)
Identifying BCBSKS Members (revised 5/2009)
- Identification Card
- Common Law Spouses
- Handicapped Dependent
- Children By Adoption
- Affidavit Dependents
- Birth Mothers
- Administrative Services Only (ASO) Groups
Communications (revised 3/2009)
- Web Site
- www.bcbsks.com
- Interactive Voice Response (IVR)
  - Inquiries
  - Mail
  - Email
- Telephone
- Overpayments
- Refund/Deduct Authorization
- Refund Request
- Automatic Deduction
- Credit Balance Audits
Other Party Liability/Ridered Conditions/Waiting Periods (revised 8/2009)
- What is OPL
- Submitting the claim
- Timely filing
- BlueCard (ITS)
- Avoiding Delays
- Reconciling Your Account
- Duplicate Coverage
- Worker’s Compensation
- No-Fault Auto
- Subrogation
- Ridered Condition
- Waiting Periods
- Forms
- Multiple Insurance Carriers Assuming Primary Responsibility
Prior Authorization/Precertification of Admissions/Services (revised 2/2010)
- Prior Authorization of Services (all providers)
- Pre-Admission Certification/Concurrent Review – Inpatient Care (hospitals/medical care facilities)
- Health Management Strategies/Value Options (hospitals/medical care facilities)
- Information Needed for Pre-Admission Certifications (hospitals/medical care facilities)
- Outcome and billing of Pre-Admission Certification (hospitals/medical care facilities)
- General Medical Stay Paid by DRG and Non-MAP’d DRG
- Inpatient Stay Paid By Per Diem
- Inpatient Admissions to a Hospital Based Skilled Nursing Facility (SNF) or Swing Bed Unit
- Home Health Authorizations
- Hospice Authorizations
- Dialysis Services Authorizations
- Birthing Center Authorizations
Compliance and Appeals (revised 2/2010)
- Utilization Review Compliance Policy
- Appeals
- Notice of Personal Financial Obligation
- Medical Necessity Definition
- Experimental/Investigational Definition
Benefits/Exclusions
- General Exclusions
- Inpatient Services
- Inpatient Days
- Medical
- Mental Health
- Room Coverage
  - Counting Days
  - Late Discharges
- ICU/CCU Requirements
- Transplants
- Outpatient Services
- Outpatient Surgery – hospitals only
- Reference Services – hospitals only
- Observation – hospitals only
- Accidental Injury
- Medical Emergency
  - Outpatient Pharmacy – hospitals and dialysis facilities
  - Partial-Day Treatment Program
  - Sleep Study/Polysomnography Services – hospitals only
  - Chemotherapy - hospitals only
  - Diabetic Education
  - Medical Nutritional Therapy (MNT)
  - Pulmonary Rehabilitation – hospitals only
  - Cardiac Rehabilitation – hospitals only
  - Positron Emission Tomography (PET) Scans
  - Health Fair Services
Birthing Center
- General Guidelines
- Prior Authorization
- Claim Submission
End Stage Renal Disease Facilities (revised 5/2009)
- General Guidelines
- Composite Rate
  - Routine items and services
  - Laboratory
  - Drug
- EPO
- Non-Invasive Vascular Studies
- Blood
- Billing
  - Type of Bill UB-04/837I Form Locator 4
  - Line Item Date of Service UB-04/837I Form Locator 45
  - Condition, Occurrence, Occurrence Span and Value Codes UB-04/837I Form Locators 18-41
  - Revenue Codes UB-04/837I Form Locator 46
Home Health Agency
- Overview
- General Guidelines
- Case Management
- Home Care Benefits
- Covered Services
- Determining If A Patient Is Homebound
- Prior Authorization
  - Payment Reduction When Prior Authorized is not obtained
  - Sample – Prior Authorization Letters (Also see section 6: Prior Authorization/Precertification of Admissions/Services)
- Appeals – Refer to Section 7: Compliance and Appeals
- Billing and Reimbursement
  - Type of Bill
  - Reporting of Revenue Codes
  - Reporting of HCPCS/CPT Codes
  - Line Item Date of Service
  - Revenue Code List
Hospice
- Overview
- General Guidelines
- Case Management
- Home Care Benefits
- Prior Authorization
  - Hospice Initial Evaluation
  - Skilled Nursing Visits
  - Payment Reduction When Prior Authorization is Not Obtained
  - Sample – Prior Authorization Letter
- Appeals – Refer to Section 7: Compliance and Appeals
- Reimbursement
- Frequently Asked Questions
- UB-04/837I Claim Form
  - Type of Bill
  - Reporting of Revenue Codes, HCPCS/CPT and Units
  - Line Item Date of Service
Hospitals
- General Guidelines
- Case Management
- Extension of Benefits – Change of Insurance Carriers During An Inpatient Stay
- Patient's Reason For Visit – Outpatient Claims
Substance Abuse Facility
- General Guidelines
- UB-04/837I Claim Form
  - Type of Bill UB-04/837I Form Locator 4
  - Revenue Code – UB-04/837I Form Locator 42
  - HCPCS/CPT – UB-04/837I Form Locator 44
  - Line Item Date of Service – UB-04/837I Form Locator 45
  - Units – UB-04/837I Form Locator 46
BlueCard Program (revised 8/2009)
- What is the BlueCard® Program?
  - Definition
  - BlueCard® Program Advantages to Providers
  - Accounts Exempt from the BlueCard® Program
- How Does the BlueCard® Program Work?
  - How to Identify BlueCard® Members
  - Consumer Directed HealthCare and Health Care Debit Cards
  - Coverage and Eligibility Verification
  - Utilization Review
- Claim Filing
  - Medicare Related Claims (Traditional Medicare)
  - Coding
  - Medical Records
  - Adjustments
  - Appeals
  - Coordination of Benefits (Other Party Liability)
  - Claim Payment
  - Claim Status Inquiry
  - Calls from Members
- BlueCard® Program Products
  - BlueCard® Traditional
  - BlueCard® PPO
  - BlueCard® Managed Care/POS
  - HMO
  - Medicare Advantage
- Glossary of BlueCard® Program Terms
- BlueCard® Program Quick Tips
Blue Choice (revised 8/2009)
- Identifying Blue Choice Members
- Blue Choice Provider Network
- Prior Authorization
Complementary to Medicare (revised 2/2010)
- Plan 65
- Disability Plan
- Lifetime Reserve Days
- Part B Ancillaries
- Extended Hospital Days
- Plan 65 Select
- Medicare Exclusion Rider
- Medicare Crossover
- How to Request an Update to the BCBSKS Eligibility File
- How to Submit a Paper Request to BCBSKS For Payment of Medicare Balances
Federal Employee Program (revised 1/2010)
- FEP Customer Service Center
- New Directions
- Standard Option Benefit Recap
- Basic Option Benefit Recap
- Basic Consumer Option
- Inpatient Admissions for Member Age 65 or Older and Does Not Have Medicare
- Maternity Admissions
Specialty Network Groups
- Listing of Groups
- Claims Submission
- Claims Pricing
- Claims Payment
- Inquiries/Pre-Admission Certification
State of Kansas Employee Group (revised 3/2009)
- Kansas Choice
  - Plan A
  - Plan B
- Retirees
Remittance Advice Guide (revised 7/2009)
UB-04/837I Claim Form
Glossary (new 2/2010)