Blue Cross and Blue Shield of Kansas is excited to offer providers a new tool: Medical Policy and Precertification/Pre-Authorization Router.  This new tool will:

• Improve access to information
• Improve your overall pre-claim experience with out-of-area patients
• Provide "one-stop-shop" for medical policy and precertification information
• Provide administrative ease for providers
• Eliminate some out-of-area claim issues

The Medical Policy and Precertification/Pre-authorization Router became available October 1, 2010.

BlueCard provider satisfaction surveys continue to emphasize the need for BlueCard processes to improve.  The Medical Policy and Precertification/Pre-authorization Router was created to give providers easier access to out-of-area Plans' medical policies and precertification/pre-authorization information (not applicable to the Federal Employee Program (FEP) or Medicare Advantage).  While providers are aware of or are used to having access to Blue Cross and Blue Shield of Kansas (BCBSKS) medical policies and precertification/pre-authorization requirements through BCBSKS' Web site, providers did not have easy access to the same information for out-of-area members.  The router will enable providers to look up medical policies applicable to their out-of-area patients and apply this information in the course of treatment, as well as precertification/pre-authorization requirements which may prevent claim issues and claim denial after the services have been rendered.  

Access to the out-of-area Plan's requirements is an easy process.  Providers are not required to log-in or be authenticated to access this information.  Providers simply:

For Medical Policy Information Go to the BCBSKS Web site – www.bcbsks.com.   Click "For Providers" Click on Medical Policies in the left hand column.  Click Medical Policies under Institutional Relations Enter the first three alpha characters of the member's identification number in the space provided and click GO.  The provider is taken directly to that member's Home Plan medical policies.  If the Home Plan's medical policies are located in their secure area, the provider will not be allowed to navigate to other areas of that Web site. The Home Plan will present providers with the following information regarding their medical policies: Policy title/name Policy statement and/or coverage criteria Policy guidelines Effective date of policy Benefit application Procedure/diagnosis code or billing codes when applicable Ability to search policies

For Precertification/Prior-authorization Information Go to the BCBSKS Web site – www.bcbsks.com.  Click "For Providers" Click on Precertification/Prior-authorization in the left hand column.  Enter the first three alpha characters of the member's identification number in the space provided and click GO.  The provider is taken directly to that member's Home Plan precertification/prior-authorization page.  If the Home Plan's information is located in their secure area, the provider will not be allowed to navigate to other areas of that Web site. The Home Plan will offer providers the following information regarding precertification/pre-authorization: Disclaimer letting providers know of any limitation General list of services that require precertification/pre-authorization Phone number to connect the provider directly to the appropriate area

Electronic RA (835) Information
With the changes in HIPAA 5010, Plans will be required to include a URL to the payer's medical policy on the provider's electronic remittance advice (HIPAA transaction 835) IF

• the payment is adjusted in accordance with the Payer's published Healthcare Policy Code, AND
• the service denied is related to medical policy as identified by specific Claim Adjustment Reason Codes, AND
• the Payer's medical policies on their public Web site are enumerated, AND
• the Payer wishes to supply this policy detail to reduce provider inquiries. 

Since the above are "and" statements rather than "or" statement, all four indicators would need to be true for the payer's URL to be required.  Providers should note that not all Plans have enumerated their medical policies.  For example, BCBSKS medical policies are not enumerated.

Should the link be provided, it will allow providers the ability to reference the medical policy applicable to the denial.  The URL is not required to link to the exact policy involved but rather to the Web page where the policy can be found.  In addition to the URL, which is provided one time at the beginning of the 835 transaction, there is a segment in the Service Payment Loop where the policy identification number is provided. 

Podcast
A Provider Podcast on this same topic can be viewed at http://www.bcbsks.com/CustomerService/Providers/podcast.htm.