Publications - Manuals & Workshop Handouts

Institutional Provider Manual

Entire Manual (Large PDF, 2.3MB, 310 pages, revised 1/2011)

Download the manual by sections:

• Preface
• About Blue Cross and Blue Shield of Kansas

1. Introduction (revised 3/2009)
2. Institutional Relations Staff (revised 1/2011)
3. 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
4. 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
5. Other Party Liability/Ridered Conditions/Waiting Periods (revised 12/2010)
   • 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
6. 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
7. Compliance and Appeals (revised 2/2010)
   • Utilization Review Compliance Policy
   • Appeals
   • Notice of Personal Financial Obligation
   • Medical Necessity Definition
   • Experimental/Investigational Definition
8. Benefits/Exclusions (revised 9/2010)
   • General Exclusions
   • Inpatient Services
   • Inpatient Days
     • Medical
     • Mental Health
     • Room Coverage
     • ICU/CCU Requirements
     • Member in hospital on Benefit Effective Date
   • Transplants
   • Outpatient Services
     • Outpatient Surgery
     • Reference Services
     • Observation
     • Accidental Injury
     • Medical Emergency
     • Outpatient Pharmacy – hospitals and dialysis facilities
     • Partial-Day Treatment Program
     • Sleep Study/Polysomnography Services
     • Chemotherapy
     • Diabetic Education
     • Dietary and Nutritional Patient Education
     • Medical Nutritional Therapy (MNT)
     • Pulmonary Rehabilitation
     • Cardiac Rehabilitation
     • Positron Emission Tomography (PET) Scans
     • Health Fair Services
9. Birthing Center (revised 8/2010)
   • General Guidelines
   • Prior Authorization
   • Claim Submission
10. 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
11. Home Health Agency (revised 6/2011)
    • 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
12. 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
13. Hospitals (revised 9/2010)
    • General Guidelines
    • Case Management
    • Extension of Benefits – Change of Insurance Carriers During An Inpatient Stay
    • Patient's Reason For Visit – Outpatient Claims
14. Substance Abuse Facility (revised 6/2011)
    • 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
15. 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
16. Blue Choice (revised 8/2009)
    • Identifying Blue Choice Members
    • Blue Choice Provider Network
    • Prior Authorization
17. 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
18. Federal Employee Program (revised 1/2011)
    • 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
19. Specialty Network Groups
    • Listing of Groups
    • Claims Submission
    • Claims Pricing
    • Claims Payment
    • Inquiries/Pre-Admission Certification
20. State of Kansas Employee Group (revised 1/2011)
    • Kansas Choice
      • Plan A
      • Plan B
    • Retirees
21. Remittance Advice Guide (revised 7/2009)
22. UB-04/837I Claim Form (revised 9/2010)
23. Glossary (new 2/2010)
24. Ambulatory Surgical Center (ASC) (new 7/2010)
    • General Guidelines
    • Claims
    • Billing
    • Payment
    • Credit Balance Audits