December 2, 2013
All Blue Cross Contracting ProvidersFrom:
Connie Winkley – Education/Communication Coordinator
Institutional Provider Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association
Electronic Provider Access (EPA) for Pre-Service Review of Out-of-area Blue Members
The Blue Cross and Blue Shield Plans are launching a new tool on January 1, 2014, that will give providers the ability to access out-of-area member’s Blue Plan (Home Plan) provider portals to conduct electronic pre-service review. The term pre-service review is used to refer to pre-notification, precertification, pre-authorization and prior approval, including other pre-claim processes. Electronic Provider Access (EPA) will enable providers to use their local Blue Plan provider portal to gain access to an out-of-area member’s Home Plan provider portal through a secure routing mechanism. Once in the Home Plan provider portal, the out-of-area provider will have the same access to submitting initial electronic pre-service review capabilities as the Home Plan’s local providers.
The availability of EPA on January 1, 2014, will vary depending on the capabilities of each Home Plan. Some Home Plans will be fully implemented and have electronic pre-service review for many services, while others will not yet have implemented electronic pre-service review capabilities. The following describes how to use EPA and what to expect when attempting to contact Home Plans at different stages of implementation.
Using the EPA Tool
The first step for BCBSKS providers is to go to http://www.availity.com and log-in as you do today. You can access the BCBSKS electronic precertification system in BlueAccess by using the Payer Resources tab on the Availity Web Portal and clicking through the appropriate links to access BlueAcess. You will then select the menu option Pre-Service Review for Out-of-Area Members (includes notification, pre-certification, pre-authorization and prior approval) on the pre-certification options web page in BlueAccess.
After clicking on Pre-Service Review for Out-of-Area members the BCBSKS provider will be taken to the following screen to submit the out-of-area member's alpha prefix from the member's ID card. The alpha prefix is the first three alpha characters that precede the member ID number.
Entering the member’s alpha prefix from the ID card will automatically route you to the Home Plan EPA landing page. This page will welcome you to the Home Plan portal and indicate that you have left the Blue Cross and Blue Shield of Kansas portal.
The Home Plan landing page will look similar across Home Plans, but will be customized to the particular Home Plan based on the electronic pre-service review services they offer. Below is an example of how a Home Plan's landing page for an out-of-area member may appear.
The landing page will allow you to connect to the available electronic pre-service review processes. Because the screens and functionality of each Blue Home Plan pre-service review processes vary widely, Home Plans may include instructional documents or e-learning tools on the Home Plan landing page to provide instruction on how to conduct an electronic pre-service review. The page will also include instructions for conducting pre-service review for services where the electronic function is not available.
BCBSKS providers are encouraged to visit the BCBSKS Precertification Web page to view detailed information on the EPA in the Precertification Manual (pages 29-31).
Outcomes when submitting the member's alpha-prefix:
Given that Home Plans are in various stages of implementation, not all routes will result in a completed pre-service review. The following is what to expect, depending on the implementation status of the Home Plan to which you have been routed.
Scenario 1: Real-time electronic pre-service review is available for the service you are seeking.
The Home Plan landing page will list the services for which electronic pre-service review is available. From this page you will connect to the Home Plan’s (or its vendor’s) pre-service review processes. You will enter the necessary information and the Home Plan will approve or deny the pre-service review request in real-time.
Scenario 2: Electronic pre-service review is available for the service you are seeking, but not in real-time.
The Home Plan landing page will list the services for which electronic pre-service review is available. From this page you will connect to the Home Plan’s (or its vendor’s) pre-service review processes. You will enter the necessary information and the Home Plan will provide an automated response that the pre-service review has been pended and inform you as to how the results of the final review will be communicated to you. In most cases, the Home Plan will email, phone or fax you with the final determination.
Keep in mind that not all Home Plans provide pre-service review 24 hours a day. This information will be posted on the Home Plan landing pages informing providers of the hours of operation.
Scenario 3: Electronic pre-service review is available, but not for the particular service for which you are seeking pre-service review.
The Home Plan landing page will list the services for which electronic pre-service review is available. For other services, the Home Plan will include instructions for how to conduct pre-service review. Home Plans will most likely list a direct phone number or provide a form that you can download and fax for pre-service review.
Frequently Asked Questions
How do I know if inpatient precertification is required for the Home Plan?
Providers can first check whether pre-certification is required by the Home Plan by accessing the Home Plan’s pre-certification requirements pages by using the medical policy router and entering the member's alpha-prefix.
What happens if I am not routed to the Home Plan?
In some instances, you will receive an error message when you enter the alpha prefix. This error message may alert you that you have not entered the appropriate number of alpha prefix characters, that the alpha prefix is inactive, or that you have entered an alpha prefix for an FEP member. (FEP alpha prefixes, which start with the letter “R,” are not supported by EPA.)
Some Home Plans do not currently have electronic pre-service review capabilities. You will receive an alert message with a direct phone number for conducting pre-service review for these Home Plans. For example:
Blue Cross and Blue Shield of Geography does not currently conduct electronic pre-service reviews. Please call xxx.xxx.xxxx for pre-service review.
Some Home Plans only allow providers who are under contract with the local Blue Plan to access their Home Plan provider portal. In this event, a non-Blue provider may see the following alert when attempting to enter an alpha prefix for a member from a Home Plan with such a restriction:
Blue Cross and Blue Shield of Geography only allows Blue contracted providers to conduct electronic pre-service review. Please call xxx.xxx.xxxx for pre-service review.
What should I do if I enter the member alpha prefix and nothing happens?
We hope these situations are rare as we work through early implementation issues. However, if this should happen, providers should call 1-800-676-BLUE to be routed to a Home Plan for telephonic pre-service review.
When will all Home Plans have EPA capabilities?
Blue Cross and Blue Shield of Kansas will keep providers updated as to Home Plan EPA implementation status.
Who do I contact if I have additional questions?
If you have any questions on how to use the EPA tool or general questions, please call Connie Winkley, BCBSKS Education Coordinator, at 1-785-291-7236.