Blue Cross and Blue Shield of Kansas Update

All Payers Workshop

December 5, 2014

Presented by Sally Stevens

Kansas Solutions

• A new BCBSKS subsidiary • Effective January 1, 2015• Limited network – BCBSKS' 103-county

service area only! Excludes Johnson & Wyandotte Counties in KS

• Represented by an empty suitcase • Sold to individuals on and off the exchange

and small group (SHOP) markets• Claims for Solutions members will have its

own remittance advice (RA)

Kansas Solutions• Blue Solutions is not a traditional HMO:

– Members will  NOT choose a Primary Care Provider (PCP)

– No referral is needed for visiting a specialty provider

– Members have open access through the BCBSKS Blue Choice  network

– Providers reimbursed using Blue Choice payment rates

Kansas Solutions

Kansas Solutions

The following alpha prefixes will be used for Kansas Solutions members:

• XSC  - Individual Exchange Solutions

• XSG  - SHOP Exchange Solutions

• XSQ -  Individual Solutions Off-Exchange

• XSR  - Small Group Solutions Off-Exchange

Kansas Solutions

Kansas Solutions

Affordable Care Act (ACA) Grace

Period• ACA mandates a three-month grace period for individual members who:

– receive a premium subsidy

– have paid at least one month's premium– are delinquent in paying their portion of

premiums

Affordable Care Act (ACA) Grace

Period• BCBSKS will:

– pay the claims with a date of service in the first month of being delinquent

– pend the claims with a date of service in the second and third month of being delinquent

– providers will a receive a letter when claims are pending

Affordable Care Act (ACA) Grace

Period• Providers cannot bill the patient during the three-month grace period.

• Provider can bill the patient once they have received a remittance

advice advising the adjudication of the claim.

• If the patient purchases coverage through the Marketplace again

and they meet the ACA grace period mandate, the patient can have

coverage again and not have to remit payment for the previous

delinquent dues.

• Availity will display delinquent information for month two and three beginning January 1, 2015.

ICD-10 Testing• Two types of testing:

1. Acknowledgement testing: Healthcare payer confirms that a test claim can be accepted, but doesn't test how it will be reimbursed.

2. End-to-End testing: Healthcare payers will submit a test claim through the payers claim adjudication system and report the reimbursement to the provider.

ICD-10 Testing• Acknowledgement testing is testing with the

provider's vendor/clearinghouse etc.; not the payer. – ICD-10 test claim is created– Test claim is transmitted to your clearinghouse

or ASK – Front-end edits, including validation of ICD-10

code set, will be applied– Acknowledgments (999 and 277CA) will be

generated – No test 835 will be returned

ICD-10 Testing• End-to-End testing is testing with the payer

• Testing begins February 2015

• Providers need to request set-up in the test system– ICD-10 test claim is created– Test claim data is submitted to BCBSKS via a

spreadsheet– Test claim is transmitted to your clearinghouse or ASK – Front-end edits, including validation of ICD-10 code

set, will be applied– Acknowledgments (999 and 277CA) will be

generated – Test 835 will be returned

ICD-10 Testing• Providers testing could see unexpected

rejections• Testing benefits you and the payers• Final thoughts on ICD-10 Testing:

– budget for and expect delays– review acknowledgements and utilize claim

status resources – www.ask-edi.com– http://www.bcbsks.com/CustomerService/Pro

viders/icd-10/index.htm

Corrected Claims• Increases administrative expenses• Slows down payment turnaround• Reasons for filing a corrected claim:

– billing late charges (lab, physical therapy, drugs, anesthesia, recovery room, Operating Room services)

– combining outpatient services onto an inpatient claim

– add additional diagnosis code or a modifier• Work to find ways within your hospital to ensure that

all the charges are on the initial claim.

REDUCING CLAIMS IS A WIN FOR EVERYONE!

Blue Cross and Blue Shield of Kansas Update

Thank you for your time today!

Questions?