FPLIC
PROVIDER POLICY & PROCEDURE MANUAL
TABLE OF CONTENTS


A. WELCOME & INTRODUCTION

B TELEPHONE DIRECTORY & FAX NUMBERS

C. INDEX

D. GLOSSARY OF TERMS

E. ADMISSION/DISCHARGE

F. ANCILLARY PROVIDERS

G. APPEALS

H. BEHAVIORAL HEALTH

I. BILLING INFORMATION

K. HEALTH IMPROVEMENT/DISEASE MANAGEMENT

L. HIPAA

M. INQUIRIES

N. INSURED/MEMBER(S) OVERVIEW

O. LEGISLATIVE

P. MEDICAL MANAGEMENT REVIEW

Q. POLICIES

WELCOME

First Priority Life Insurance Company, (FPLIC), an affiliate of Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Blue Shield, welcomes you as a participating provider. As the managing partner of FPLIC, BCNEPA welcomes and values the opportunity to work with you in providing quality care to our BlueCare Traditional/Major Medical and PPO insured/member(s).

FPLIC is committed to forging a strong, supportive partnership with network health care providers. Together, FPLIC, and its network of providers set the standards for progressive, high quality medical care that is also cost-effective.

This manual does not contain benefit information. Please call the phone numbers listed in the Telephone Directory (Section B, page 1) or refer to the phone number listed on the back of the insured/member(s)'s identification card.

Please be advised that the monthly Provider Bulletin serves as an update to this Policy and Procedure manual.

BLUECARE PRODUCTS

Blue Cross of Northeastern Pennsylvania (BCNEPA) and Highmark Blue Shield (Highmark) have restructured the relationship they have shared for many years. Highmark now shares ownership with BCNEPA of the First Priority Life Insurance Company, (FPLIC) and will be providing certain administrative services.

FPLIC offers several products. The new product names are as follows:

Copayments and coinsurances may apply and may vary by group. For benefit information, please see the Telephone Directory (Section B, page 1) for the appropriate BlueCare Service Representative phone number.

MISSION/VISION

OUR MISSION:

To provide innovative solutions that support more affordable health care, promote personal accountability for health and wellness, and to offer superior service and partnership to the constituents we serve.

OUR VISION:

To be at the forefront of innovation and delivery of improved health management and financing services that promote healthier communities.

ROLE OF THE PROVIDER RELATIONS DEPARTMENT

The Provider Relations Department, which is part of the overall Provider Advocacy Division of BCNEPA, plays an integral role in network development and maintenance. The department is comprised of the following staff:

Director Consultants

Regional Managers Analysts

Administrative Assistants Provider System Support

Some of the responsibilities of personnel include, but are not limited to:

For all your needs, Provider Relations is just an e-mail or phone call away at (570) 200-4700 or 1-800-451-4447, Monday through Friday, 8:00 a.m. – 5:00 p.m.

For claims, benefits and eligibility information, please see the Telephone Directory (Section B, page 1) for the appropriate BlueCare Service Representative phone number.

FPLIC insured/member(s) should be directed to call the appropriate BlueCare Service Representative phone number listed in the Telephone Directory, (Section B, page 1), Monday through Friday,

8:00 a.m. - 5:00 p.m. with any questions regarding their coverage. Hearing and/or speech-impaired insured/member(s) may call (TTY/TDD) 1-866-280-0486.

FPLIC
TELEPHONE DIRECTORY
Business Hours are Monday through Friday, 8:00 a.m. to 5:00 p.m., unless otherwise stated.

Behavioral Health – Blue Cross of NEPA For all others, refer to the ID card.   1-800-577-3742 Fax: 1-888-548-8013  
BlueCare Service Representatives (Insured/Member)
  • BlueCare Traditional/Major Medical
  • BlueCare PPO
  • BlueCare Comprehensive Major Medical


1-800-829-8599 
1-888-338-2211
1-888-338-2211
Case Management 1-800-346-6149
BlueCare Service Representatives (Provider)
  • BlueCare Traditional/Major Medical
  • BlueCare PPO
  • BlueCare Comprehensive Major Medical


1-888-827-7117 
1-866-262-5635
1-866-262-5635
E-Services (Electronic Billing) (570) 200-1410 (570) 200-1405  
Hearing and/or Speech-impaired (TTY/TDD) 1-866-280-0486  
Pre-admission Certification (Utilization Management) Blue Cross of NEPA 8:00 a.m. to 4:00 p.m. (M-F)
  • BlueCare Traditional/Major Medical
  • BlueCare PPO
  • BlueCare Comprehensive Major Medical
Fax: (570) 200-6788 


1-800-638-0505 
1-866-262-5623 
1-866-262-5623
Medical Directors 1-800-462-0900
Provider Relations 1-800-451-4447 
(570) 200-4700 
Fax: (570) 200-6880
Pharmacy Management Program 1-800-722-4062
Fax # (570) 200-6870

FPLIC INDEX

ITEM Section Page
Adjustments (electronic and paper) I 3
Admission/Discharge E 1
Ambulance F 4
Ambulatory Surgical Services F 3
Ancillary Providers F 1
Appeals G 1
Automobile Insurance I 8
Behavioral Healthcare Program H 1
Benefit/Eligibility Information E 1
Billing Information I 1
Billing Policies/Procedures I 1
BlueCare Products A 1
Case Management Program E 1
Chemical Recovery F 4
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) I 8
Claim Adjustment Policy I,Q 4,1
Clinical Code Editor P 1
Collection of FPLIC Insured/Member(s) Liability I 2
Concurrent Processing I 2
Concurrent Review E 1
Coverage by Two Plans I 6
Delay/Cancellation Policy/Against Medical Advice (AMA) I 2
Dependent Children I 7
Detained Baby Claims I 1
DRG Review Process P 1
DRG Validation (Post Payment Review) P 2
DRG Validation Review Unit P 1
DRG/Per Case Payment Validation Procedure P 2
Durable Medical Equipment F 4
Elective Admissions E 3
Emergency Room Admissions E 2
Emergency/Urgent Admissions E 3
Explanation of Benefits (EOB) I 4
Focus PAC Appeal E 6
Focus PAC Diagnosis/Procedure List E 4
Focus PAC Notification Letter E 6
Focused Review E 3
Forms J
Glossary of Terms D 1
Health Improvement/Disease Management K 1
HIPAA L 1
Home Health Care Services F 2
Home Infusion Services F 2
Hospice Services F 2
ID Card N 1
Independent Lab F 4
Infofax M 1
Injured on Private Property/Business (other than employer) I 9
Inquiries M 1
Insured/Member(s) Liabilities I 2
Insured/Member(s) Overview N 1
Itemization of Service I 1
Legislative O 1
Magnetic Resonance Imaging (MRI) F 4
Maternity Admissions E 4
Maternity Home Health Visit I 1
Medicaid I 8
Medical Criteria E 2
Medical Management Review P 1
Medical Records L 1
Medicare I 7
Mission/Vision A 1
NaviNet I,M 3, 1
Newborns I 7
Non-Coordination of Benefits Plans I 6
Non-Network Hospitals E 6
NUCC 1500 Billing Requirements I 3
Orthotics F 4
Other Party Liability I 4
Out-of-Area Admissions E 6
Outpatient Services I 1
Outside Billing Agencies L 1
Policies Q 1
Postponement Policy I 2
Pre-Admission Certification (PAC) E,F 2,1
Pre-admission Testing I 1
Primary Payer I,I 4,5
Prosthetics F 4
Provider Bulletin M 1
Provider Center M 1
Provider Relations A,M 2,2
Quality Management Department P 1
Re-admission I 1
Remittance Advice (RA) I 4
Responsibility of Participating Hospital E 3
Role of Insured/Member(s) N 1
Satellites Q 1
School Insurance I 9
Secondary Payer I,I 4,5
Service Representatives M,N 1,2
Services Requiring Focused Review E 3
Services Requiring Pre-Admission Certification (PAC) E 3
Skilled Nursing Facility Services F 3
Submitting balance after insurance other than Medicare I 5
Submitting balance after Medicare I 5
Telephone Directory B 1
Terminations Q 1
Timely Filing I 1
Transfer/Benefits Exhausted E 6
Treatment of Family Members Q 2
UB04 Billing Requirements I 3
Units I 1
Utilization Review I 2
Utilization Review Unit P 3
Welcome A 1
Worker's Compensation I 9

FPLIC

GLOSSARY OF TERMS

Acute Care: Applies to services that deal with needs of short-term duration (30 days or less), that are primarily oriented toward medical problems requiring intensive attention and treatment to restore a previous state of health or to prevent the worsening of a present state, that may at times, be emergent and may have related long-term effects. From a structural point of view, such care is most commonly found in organizations like hospitals, surgical centers and some clinics.

Agreement: A written document given to the insured/member(s) that outlines benefits, exclusions, etc. Applicable to the coverage(s) applied for by the insured/member(s).

Allowable Charge: Generic term referring to the maximum fee that a third party will use to reimburse a provider for a given service.

Ambulatory Care: All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients.

Ancillary Care: Care provided by a nurse, X-ray, lab or emergency medical technicians, etc.

Ancillary Facility: An institution or entity other than a hospital which is licensed, where required, to provide covered services.

Appeal: Procedure that reviews an adverse plan determination.

Benefit Booklet: Written material provided to all insured/member(s) by FPLIC containing a summary of covered services, an explanation of how to access all benefits, and a copy of the group's specific contract.

Chronic: Of long duration.

Claim: A request for payment for services provided by a health care provider.

Coinsurance: A provision in a insured/member(s)' coverage that limits the amount of coverage by the Plan to a certain percentage, commonly 80%.

Complaint: An issue a BCNEPA insured/member(s) presents, either in writing or oral form, which is subject to the appeals procedure and/or the grievance procedure.

Concurrent Utilization Review: A review by a utilization review entity of all reasonably necessary supporting information, occurring during an insured/member(s)' hospital stay or course of treatment, resulting in a decision to approve or deny payment for health care services. The review involves a clinical update in response to current treatment approaches. This ensures that treatment is medically necessary and/or being provided in the most appropriate setting.

Coordination of Benefits (COB): Provisions and procedures used by insurers or third-party payers to avoid duplicate payment for losses covered under more than one policy or subscription agreement.

Copayment: A specified amount of covered services, expressed in dollars, that is the responsibility of the insured/member(s).

Cosmetic Procedures: Medical or surgical procedures which are intended to improve the appearance of any portion of the body and from which no improvement in physiologic function can be expected.

Cost Containment: The control of the overall cost of health care services within the health care delivery system. The cost-control measures include case management, utilization, utilization review, pre-admission certification and audit.

Coverage: The extent of benefits provided under an insured/ member(s)' contract issued by the Plan.

Covered Services: Those medically necessary health services that an insured/member(s) is entitled to receive and which are eligible for payment or reimbursement under the terms of the applicable Plan document.

Credentialing: Internal certification process prior to acceptance into FPLIC network.

Deductible: That portion of covered hospital and medical charges that an insured/member(s) must pay before the Plan's liability begins.

Diagnosis: The identity of a condition or cause of disease; e.g., admitting diagnosis, discharge diagnosis, final diagnosis, etc.

Diagnostic Related Group (DRG): Diagnostic related group refers to a hospital payment arrangement that provides a prospective rate based on the patient's diagnosis. With DRG, the provider assumes the financial risk of managing the care of an individual, regardless of the length of stay, for a fixed amount based on the patient's diagnosis.

Durable Medical Equipment (DME): Equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of an illness or injury; and is appropriate for use in the home.

Elective Surgery: Surgery not considered an emergency because reasonable delays will not affect the outcome unfavorably, even though such surgery is necessary and may be major.

Emergency Medical Condition: Any health care service provided to an insured/member(s) after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Explanation of Benefits (EOB): A statement to the insured/member(s) and applicable provider which explains action taken on each claim.

Grievance: A request by an insured/member(s) or a provider with his/her written consent, to have FPLIC or a utilization review entity review the denial of a health care service based on medical necessity and appropriateness.

Home Health Care Agency: An accredited facility that:

  1. Provides skilled outpatient services on a visiting basis in the insured/member(s)' home; and
  2. Is responsible for supervising the delivery of such services under a plan authorized by the insured/member(s)' physician.

Home Infusion Therapy Agency: A facility/other provider that provides hi-tech services designed to coordinate the effective provision of physician-directed nursing, pharmacy and related services necessary to conduct a parenteral/enteral regime safely and effectively in the patient's home.

Hospice: A facility/other that is primarily engaged in providing palliative care to terminally ill individuals.

Hospital: A provider that is a short-term, acute care or rehabilitation hospital and:

  1. Is a duly licensed institution;
  2. Is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of physicians;
  3. Has organized departments of medicine and/or major surgery;
  4. Provides 24-hour nursing service by or under the supervision of registered nurses; and
  5. Is not, other than incidentally, a:

(Hospital continued): - Skilled nursing facility;

- Nursing home;

-Custodial care home;

- Health resort;

- Spa or sanitarium;

- Place for rest;

- Place for the aged;

- Place for the treatment of mental illness;

- Place for the provision of hospice care; or

- Personal care home.

Hospital Compensated Physician: A physician who provides services in a hospital setting and has a contractual relationship with the hospital (e.g., is paid a salary by the hospital or receives compensation from or through the hospital).

Independent Laboratory: A laboratory which is independent both of the attending or consulting physician's office and of the hospital.

Inpatient: An insured/member(s) who is treated as a registered overnight bed patient in a hospital or facility/other provider.

Insured/Member: Person who is properly enrolled in BlueCare and who otherwise is entitled to receive covered services under a Plan document. An insured/member(s) can be either the policy holder or a dependent.

Medicaid: Grants to states for assistance programs as set forth in Title XIX of the Social Security Act, amended from time to time.

Medical Criteria: Predetermined elements of health, the presence, absence and completeness of which indicate the quality of medical services.

Medical Necessity or Medically Necessary: Services or supplies rendered by a provider that are determined:

(a) Appropriate for the symptoms and diagnosis or treatment of the insured/member(s)' condition, illness, disease or injury; and

(b) Provided for the diagnosis, or the direct care and treatment of the insured/member(s)' condition, illness, disease or injury; and

(c) In accordance with the current standards of medical practice; and

(d) Not primarily for the convenience of the insured/member(s) or the insured/member(s)' provider; and

(e) The most appropriate source or level of service that can safely be provided to the insured/member(s). When applied to hospitalization, this further means that the insured/member(s) requires acute care as an inpatient due to the nature of the services rendered or the insured/member(s)' condition, and the insured/member(s) cannot receive safe or adequate care as an outpatient.

Medical Record Reviews: Process performed by BCNEPA to monitor the appropriateness of care, consistency of charting and completeness of records. The content of the insured/member(s)' record is documentation of the quality of the care provided. Quality providers must consistently maintain both excellent medical care standards and follow-up with comprehensive documentation. Medical record reviews can be conducted in a hospital and/or ambulatory system.

Medicare: A third-party reimbursement program administered by the Social Security Administration that underwrites the medical costs of qualified persons age 65 and over and some qualified persons under age 65. "Part A" covers hospital services and related care; "Part B" covers physician services and other health services, sometimes referred to as Title XVIII of the Social Security Act.

MH/CR: Mental health/chemical recovery.

Observation: A stay to determine or monitor a patient for possible admission.

Open Enrollment: The time frame during which individuals may elect to enroll in a health insurance plan or prepaid group practice.

Outpatient: An insured/member(s) who receives services or supplies while not an inpatient.

Pre-admission Certification (Prospective A review by a utilization review entity of all reasonably

Utilization Review): necessary supporting information that occurs prior to the delivery or provision of a health care service resulting in a decision to approve or deny payment for a health care service. The review assesses the appropriateness of all elective inpatient admissions and other ancillary services based upon nationally recognized and/or internally developed criteria.

Pre-admission Testing: Routine tests and examinations performed in an outpatient facility or the outpatient department of a hospital prior to a scheduled admission.

Prosthetic Devices: Items (such as artificial limbs) used as substitutes for body parts.

Quality Management: The process of objectively and systematically monitoring and evaluating the quality, timeliness, and appropriateness of care.

Regional Referral Center: BCNEPA's dedicated unit that provides eligibility verification, triage, referral and utilization management for behavioral health care services.

Remittance Advice (RA): A statement to the facility which explains action taken on each claim.

Retrospective Utilization Review: A review by a utilization review entity of all reasonably necessary supporting information, occurring following delivery or provision of a health care service resulting in a decision to approve or deny payment for a health service.

Secondary Payer: The contract which pays the balance (or up to contract limits) when an insured/member(s) has two contracts and primary benefits are provided by the contract.

Self-Funded: A health care program in which employers assume the risk for medical costs, funding benefit plans from their own resources without purchasing insurance. Self-funded plans may be self-administered or the employer may contract with an outside administrator for an administrative service only.

Self-Insured: An individual or group of individuals, employer, or organization that assumes complete financial responsibility for medical expenses.

Short Procedure Unit (SPU): A service which requires a stay of less than 24 hours.

Skilled Nursing Facility (SNF): An institution or a distinct part of an institution that provides skilled nursing care and rehabilitation services to patients who do not require full hospital care.

Subrogation: The act of attempting to recover money that FPLIC has paid for services for which a third party, who has caused injury to an insured/member(s), or the third party's insurance carrier, is liable.

Utilization: The extent of usage of Plan benefits by an insured/ member(s).

Utilization Review: A system of prospective, concurrent and retrospective utilization review of the medical necessity and appropriateness of the health care prescribed, provided or proposed to be provided to an insured/member(s).

Worker's (or Workmen's) Compensation: A state law that assigns liability to the employer for injury or illness resulting from on-the-job accidents or conditions.

ADMISSION/DISCHARGE
BENEFIT/ELIGIBILITY
INFORMATION

For information on benefits and eligibility, please contact the appropriate BlueCare Service Representative or utilize NaviNetsm.

Refer to the Telephone Directory (Section B, page 1) for the appropriate phone numbers.

CASE MANAGEMENT PROGRAM

The Case Management Program of Blue Cross of Northeastern Pennsylvania is a voluntary program offered to BlueCare insured/member(s) as part of their benefit package at no additional cost. Case Management's role is to coordinate necessary interventions and services with an individual's health care needs in a quality and cost-effective manner. The program is proactive and may begin prior to the occurrence of any actual utilization, in anticipation of preventing the utilization from occurring.

Intervention may occur at any point in the continuum of care, i.e., prior to hospitalization, during hospitalization, and post hospitalization.

Potential cases can be referred to case management, internally or externally, by medical directors, utilization management staff or other internal departments, providers, social workers, discharge planners, physicians, vendors, insured/member(s), or other health care plans. Admission notification reports are generated and analyzed for possible case management involvement/intervention. Referrals are then triaged to determine the appropriateness of case management based on criteria.

The Case Management Program is designed to augment, not replace the discharge planner. Contact the Case Management Department at 1-800-346-6149 for information.

A case management assessment is available for insured/member(s) who:

CONCURRENT REVIEW

Professional nurses or licensed clinicians conduct telephonic or on-site concurrent review on specific patients admitted to inpatient hospitals, rehabilitation centers, SNFs or home health facilities which are non-DRG or out of area. Concurrent review includes review of medical necessity, discharge planning, researching and coordinating alternatives to inpatient care. Concurrent review nurses or clinicians utilize InterQual criteria and other criteria as appropriate when reviewing hospitalizations.

Inpatient psychiatric and substance abuse require continued stay reviews. Concurrent review is determined at the time of pre-admission certification. Contact Regional Referral Center at 1-800-577-3742 for eligibility and benefit information.

EMERGENCY ROOM ADMISSIONS

The participating facility emergency room personnel should evaluate and stabilize the BlueCare insured/member(s).

If a BlueCare insured/member(s) requires admission after stabilization in the emergency room, pre-admission certification is required and can be obtained by contacting the appropriate Blue Cross (BC) Utilization Management Review Department phone number as found in the Telephone Directory

(Section B, page 1).

During business hours, the BC Utilization Management Department personnel will provide the caller with a pre-admission certification number. If the BC Utilization Management Department is notified via answering machine during non-business hours, a representative from the BC Utilization Management Department will return the call on the next business day. The pre-admission certification number can be viewed via NaviNetsm once obtained through the BC Utilization Management Department.

If during business hours you do not receive a phone call from the BC Utilization Management Department, the BC insured/member(s) should be admitted, if the admission is medically necessary. BC will return your call within 24 hours and the admission would need to be reviewed for medical necessity.

If the admission occurs after normal business hours, the admitting facility is responsible for notifying the BC Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend.

PRE-ADMISSION CERTIFICATION
(PAC)

Definition

Pre-admission certification (prospective utilization review) is a review by a utilization review entity of all reasonably necessary supporting information that occurs prior to the delivery or provision of a health care service resulting in a decision to approve or deny payment for a health care service. The review assesses the appropriateness of all elective inpatient admissions and other ancillary services based upon nationally recognized and/or internally developed criteria.

Requesting Medical Criteria

The BC Utilization Management Department bases its decision on specific criteria to determine medical necessity. These criteria are available to all BlueCare providers upon request.

Criteria may be requested by contacting or faxing the BC Utilization Management Department with the following information: insured/member(s) name, BlueCare identification number, date(s) of service, date(s) of denial and facility where services were rendered.

Blue Cross of NEPA/BlueCare
Utilization Management Department
19 North Main Street
Wilkes-Barre, PA 18711-0302

Please see the Telephone Directory (Section B, page 1) for the appropriate BC Utilization Management Department phone number.

Responsibility of Participating Hospital

The participating hospital shall be responsible for furnishing to BC's Utilization Management Department any required medical information relative to the pre-admission certification process.

In the event that one of the following situations occurs, an inpatient admission may be denied and the participating hospital may not charge either FPLIC or the insured/member(s) for services rendered with respect to such admission.

  1. A pre-admission certification was required, but not performed, and the participating hospital, nonetheless, admitted the insured/member(s);
  2. A pre-admission certification was required and performed, but the admission was medically denied by FPLIC. The participating hospital admitted the insured/member(s) without adequate prior written notice to the insured/member(s) that the admission would not be paid by FPLIC, and without the insured/member(s) acknowledging this fact in writing, together with a request to be admitted and to assume financial responsibility; or
  3. A pre-admission certification was required and performed, but the admission was an inappropriate admission, and the diagnosis/procedure treated or performed differed from that certified and approved.

Services Requiring Pre-Admission Certification (PAC)

  1. All out-of-area in patient admissions regardless of group or individual contract, require pre-admission certification for every inpatient admission with the exception of maternity admissions.
  2. All inpatient and partial hospitalization psychiatric and chemical dependency admissions require pre-admission certification for every inpatient admission. Contact Regional Referral Center at 1-800-577-3742 to verify benefits and obtain pre-admission certification.

Focused Review

In DRG facilities, a Focus PAC program has been developed. Focus PAC requires that targeted diagnosis and/or procedures are precertified to determine medical necessity and the appropriate treatment site. Pre-admission certification is required only for the specific medical/surgical procedures outlined on pages 4 - 6 of this section.

Services Requiring Focused Review

Anything not indicated under "Services Requiring Pre-Admission Certification" above, require focused review.

How Focus PAC Works:

  1. Elective Admissions

The BC Utilization Management Department must be contacted either via NaviNetsm or telephone with the necessary medical information describing the insured/member(s) history, current condition and treatment plan.

  1. Emergency/Urgent Admissions

The BC Utilization Management Department must be contacted via NaviNetsm or telephone within 48 hours or on the first regular business day following an emergency admission with the appropriate medical information so that a specific number of inpatient days can be assigned.

  1. Maternity Admissions

Pre-admission certification is not required for maternity admissions for BlueCare insured/ member(s) either in or out of area.

If the baby is detained after the mother is discharged, pre-admission certification may be required depending on the group. Benefits and eligibility can be verified by contacting the appropriate BlueCare Service Representative phone number in the Telephone Directory (Section B, page 1).

  1. Other Services Requiring Pre-admission Certification, including but not limited to:
  1. Skilled Nursing Facility 3. SPU Complications Requiring Inpatient Stay
  2. Home Health Services 4. Physical Rehabilitation Hospitalization
  1. Secondary Payer Admissions
  1. Pre-admission certification is not required if it is determined that BlueCare benefits are secondary to another group health insurance carrier.

Focus PAC Diagnosis/Procedure List (Requires pre-admission certification only if patient is admitted as an inpatient).

NOTE: Codes are subject to change

IF AN INPATIENT CLAIM INCLUDES A PROCEDURE OR DIAGNOSIS ON THE FOCUS PAC LIST, PAC IS REQUIRED.

Inpatient Procedures (ICD9)
PAC required for the below Inpatient procedures (ICD9) only if performed on the same day as the admission date. Otherwise no PAC needed.
21.61, 21.62, 21.69 Turbinectomy
21.88, 21.5 Septoplasty
22.2, 22.31, 22.39 Antrotomy
22.63 Ethmoidectomy
26.0, 26.11, 26.12, 26.19, 26.21, 26.29,
26.30, 26.31, 26.32
Sialoadenectomy/Incision, Excision or Biopsy Salivary Gland
28.2, 28.3 T & A
28.6 Adenoidectomy
31.42 through 31.45 Laryngoscopy
33.21 through 33.24 Bronchoscopy
34.22, 34.25 Mediastinoscopy
38.59 Varicose Vein Stripping & Ligation
40.11, 40.21, 40.22 Biopsy/Simple Excision
40.23, 40.24, 40.29 Excision of Lymph Node
45.13 EGD
49.12, 49.31, 49.39 Fistulectomy
51.10 ERCP
51.23, 51.24 Laparoscopic Cholecystectomy
53.00 to 53.05, 53.10 to 53.17 Herniorrhaphy (Inguinal)
53.41, 53.49 (Umbilical)
69.01 D & E
69.09, 69.02 D & C
77.51 to 77.59 Bunionectomy
77.56 Repair of Hammertoe
79.0 through 79.09, 79.10 through 79.19 Closed Reduction of Fractures
80.21 Arthroscopy (Shoulder)
80.26 Arthroscopy (Knee)
80.27 Arthroscopy (Ankle)
80.6 Menisectomy of Knee
88.40 through 88.49 Arteriogram
Inpatient Diagnosis
NOTE: Precert is only required if diagnosis code is the Admitting Diagnosis or Primary Diagnosis.
250.0, 250.01 through 250.03, 250.9, 
250.91 through 250.93
Diabetes Mellitus
276.5, 276.50, 276.51 276.52 Volume Depletion/Dehydration
346.0 – 346.2, 346.8, 346.9, 346.01, 
346.11, 346.21, 346.81, 346.91, 307.81, 
784.0
Headache
386.3 through 386.35 Labyrinthitis
401.0, 401.1, 401.9 Hypertension
435.9 TIA
558.9 Gastroenteritis
592.0, 592.1, 592.9 Renal Colic/Kidney Stone
599.0 Urinary Tract Infection
682.0 through 682.9 Cellulitis
722, 722.0, 722.1, 722.2, 722.7, 722.10, 
722.11, 722.70, 722.71, 722.72, 722.73   

723, 723.0   

724, 724.0, 724.1, 724.2, 724.3, 724.4, 724.5, 724.6, 724.00, 724.01, 724.02, 724.09   

729.2  
Herniated Disc/Lumbar Radiculopathy/Medical Back Pain
780.4 Dizziness/Giddiness
784.0 Headache
787.0 through 787.03 Nausea & Vomiting
789.0 through 789.07, 789.09 Abdominal Pain
788.0, 592.0, 592.1, 592.9 Renal Colic/Kidney Stone
850.0 and 850.9 Concussion
  1. Morbid Obesity Surgery – requires precert. Review of specific information is required before pre-certification can be obtained. CPT: 43644, 43645, 43842, 43843, 43846, 43847, 43848
    ICD9
    : 44.31, 44.38, 44.39, 44.68, 44.95, 44.96, 44.97, 44.98
  1. All mental disorders with diagnosis codes 290.0 - 319 require pre-cert.
  2. All transplants require precert.
  3. Panniculectomy - Any Setting CPT: 15830 ICD9: 86.83
  4. Bony impacted wisdom teeth - inpatient, SPU, ambulatory surgical setting HCPCS: D7230, D7240, D7241 ICD9: 23.19
  5. CTA - outpatient hospital, freestanding imaging facilities CPT: 0144T, 0147T, 0149T

All complications of any Short Procedure Unit (SPU) that necessitates inpatient admission will require pre-admission certification.

Retrospective review will be performed on all admissions of "low severity" diagnosis, i.e. all inpatient admissions for two days or less.

Any questions, please contact the BC Utilization Management Department.

For any current updates to the previous listing, please refer to your monthly Provider Bulletins.

Out-of-Area Admissions

All out-of-area admissions, both prospectively and concurrently, will be reviewed for medical necessity and appropriate site.

BlueCare Non-Network Hospitals/Out-of-Area Admissions

All inpatient admissions to a BlueCare non-network/out-of-area hospital will require pre-admission certification. Pre-admission certification (PAC) approvals are valid for up to a sixty (60) day period from the initial request. If the admission does not occur in that time period, a new PAC will be required. The Utilization Management Department must also be notified if there is a change in the admission date.

Focus PAC Notification Letter

The attending physician, insured/member(s), and hospital without electronic capability will receive written confirmation of denials and approvals. Hospitals with electronic capability can access approvals/denials electronically, and will receive only written confirmation of denials.

Focus PAC Appeal

If the insured/member(s) or attending physician disagrees with the Utilization Management Department's determination of medical necessity, the attending physician may appeal the determination by calling the medical director at 1-800-462-0900 within 24 hours of the denial. An appeal may also be requested in writing with supporting medical records within 60 days of the denial letter, and submitted to the Regulatory Compliance Department, BCNEPA, 19 N. Main St., Wilkes-Barre, PA 18711-0302.

Transfer/Benefits Exhausted

If a BlueCare insured/member(s) is admitted and subsequently transferred to another hospital, or the insured/member(s) exhausts coverage under his/her insured/member(s) agreement before being discharged, the applicable DRG prospective payment per case rate may not apply.

If an insured/member(s) is admitted to a hospital, and subsequently transferred to an out-of-area hospital, the admitting hospital must submit a bill for the original admission.

If an insured/member(s) is transferred from an out-of-area hospital to a participating hospital, the receiving hospital shall bill for a normal DRG payment.

If an insured/member(s) is admitted to a hospital, transferred to another hospital, and then returns back to the first hospital, the original admission to the first hospital would be paid as a transfer case. The subsequent admission to the second hospital would also be considered a transfer case. The return admission to the first hospital would be paid at the DRG rate.

NOTE: Hospitals must use proper discharge status codes, (i.e. 02 - discharged/transferred to another short-term general hospital for inpatient care), as per the UB04 billing format, to ensure timely and proper payment.

Example: Transfer Payment Logic

DRG 125 – transfer case

$4,500.00 Total Charges $4,150.00 DRG payment

x 70% Transfer % - 150.00 Less subscriber/dependent(s) payable

$3,150.00 Payment $4,000.00 Net DRG payment for comparison

- 150.00 Less subscriber/dependent(s) payable

$3,000.00 Net transfer payment for comparison

Since this transfer percentage calculation resulted in a lower payment than the DRG payment, the transfer payment is utilized. If the transfer payment was higher than the DRG payment, reimbursement would be capped at the DRG amount.

Transfers to post-acute care providers (i.e., SNF's, Home Health, Psychiatric Hospitals, Rehab Hospitals, Children's Hospitals, Long-Term Care Hospitals, and Cancer Hospitals) from the following 30 DRG's will be included under this policy, effective for discharges on or after October 1, 2004:

DRG 012, 014, 024, 025, 088, 089, 090, 113, 121, 122, 127, 130, 131, 209, 210, 211, 236, 239, 277, 278, 294, 296, 297, 320, 321, 395, 429, 468, 541, 542.

ANCILLARY PROVIDERS
OVERVIEW

FPLIC's ancillary provider network is a comprehensive system of alternative health care services. The ancillary network provides a substitute to inpatient hospitalization and/or an alternative to more costly services when developing an individualized plan of care.

FPLIC's ancillary network consists of the following provider types.

FPLIC considers the following ancillaries as professional providers. BlueCare claims for these provider types are to be submitted on a NUCC 1500 claim form.

For verification of benefits, contact the appropriate BlueCare Service Representative phone number in the Telephone Directory (Section B, page 1).

PRE-ADMISSION CERTIFICATION

Pre-admission certification is required prior to most ancillary services being rendered (check your monthly Provider Bulletin for current information on pre-admission certification). Blue Cross (BC) Utilization Management Department nurse analysts are available to answer questions, precertify and make all arrangements for the requested services.

During business hours, the BC Utilization Management Department personnel will provide the caller with a pre-admission certification number. If the BC Utilization Management Department is notified via answering machine during non-business hours, a representative from the BC Utilization Management Department will return the call on the next business day. The pre-admission certification number can be viewed via NaviNetsm once obtained through the BC Utilization Management Department.

If during business hours you do not receive a phone call from the BC Utilization Management Department, the BlueCare insured/member(s) should be admitted, if the admission is medically necessary. BC will return your call within 24 hours and the admission would need to be reviewed for medical necessity.

If the admission occurs after normal business hours, the admitting facility is responsible for notifying the BC Utilization Management Department of the admission within 48 hours or the next business day if the admission occurs on the weekend.

HOME HEALTH CARE SERVICES

Benefits will be available if the insured/member(s) is homebound and the attending physician has: (1) ordered home health care, (2) received pre-admission certification approval from Blue Cross, and (3) furnished, in consultation with the participating home health agency's professional personnel prior to the first visit, a written plan of treatment stating that the services ordered are medically necessary. Continuing eligibility requires that the attending physician provide such a plan of treatment at thirty (30) day intervals.

NOTE: As of January 1, 2006, providers who are NaviNetSM enabled MUST submit the initial precertification request for home health or inpatient rehabilitation services via NaviNetSM.

Home health providers offer but not limited to the following services:

HOME INFUSION SERVICES

Home infusion is designed to provide intravenous medication or solutions to insured/member(s) at home.

Home infusion therapy providers offer but not limited to the following services:

* Prior Authorization Required by Blue Cross Pharmacy Management Department

Home infusion therapy benefits will be provided only if the insured/member(s) physician prescribes the services. Certain home infusion benefits require prior authorization by the Pharmacy Management Department by calling 1-800-722-4062. The Pharmacy Management Department's fax number is

570-200-6870. Claim submission for home infusion charges must be on a NUCC 1500 form. Refer to Section I for billing information.

HOSPICE SERVICES

Hospice care is a health care program, which provides an integrated set of services, primarily in the insured/member(s) home, designed to provide palliative and supportive care to terminally ill insured/member(s) and their families. Services are coordinated through a hospice interdisciplinary team and the insured/member(s) attending physician. The focus is on care, not cure.

BlueCare products shall provide coverage for hospice benefits when the insured/member(s) attending physician certifies in writing to Blue Cross that the member has a terminal illness with a medical prognosis of six (6) months or less and when the insured/member(s) or responsible party elects in writing to receive care primarily in the home to relieve pain. Hospice services do not require pre-admission certification.

BlueCare products will provide coverage for hospice services based on one (1) of three (3) levels of care. The hospice agency shall be responsible for administering the following services:

The following services shall be eligible for coverage to an approved essentially homebound patient by an approved hospice agency responsible for the insured/member(s) overall care:

SKILLED NURSING FACILITY SERVICES

BlueCare products shall provide coverage at a skilled nursing facility (SNF) when certified as medically necessary by a physician. Pre-admission certification is required at least forty-eight (48) hours prior to an admission to a skilled nursing facility.

Patient care in an SNF is covered if all of the following factors are met:

Rehabilitation services in an SNF include the following:

AMBULATORY SURGICAL SERVICES

Ambulatory surgical services can be safely performed in a less intensive, non-acute care environment and are generally surgical in nature but can include endoscopic/diagnostic procedures. For pre-admission certification requirements, refer to Section E, pages 4 - 6.

MAGNETIC RESONANCE IMAGING (MRI)

Magnetic resonance imaging (MRI) is a noninvasive diagnostic imaging modality. This technique uses an interaction of a magnetic field and radiofrequency waves in order to generate, with computer assistance, an image of an area of the body. MRI scans must meet the criteria of medical necessity and reasonableness. It should be performed when the results are expected to impact the diagnosis and treatment of the insured/member(s). Pre-admission certification is not required. Claim submission for MRI charges must be on a NUCC 1500 form. See Section I for billing information.

CHEMICAL RECOVERY

Inpatient detoxification is provided either in a participating hospital or on an inpatient basis in a participating non-hospital facility, which is licensed as an approved alcohol and/or drug addiction treatment program and is approved by the Pennsylvania Department of Health. Benefits may vary. Please refer to the Telephone Directory (Section B, page 1) for the appropriate BlueCare service representative phone number to verify benefits/eligibility.

Outpatient alcohol or other drug abuse services are provided in a participating facility appropriately licensed by the Pennsylvania Department of Health as an alcoholism or drug addiction treatment program.

Contact the Regional Referral Center (RRC) at 1-800-577-3742 to precertify all inpatient and outpatient treatment for BlueCare insured/member(s). In order to obtain pre-admission certification, the attending physician must provide evidence prior to ordering such treatment, in a format satisfactory to RRC, that alcohol or drug abuse treatment is medically necessary and appropriate.

DURABLE MEDICAL EQUIPMENT

Durable medical equipment (DME) is a device such as a wheelchair or walker, which can withstand repeated use, is primarily used to serve a medical purpose and would also be appropriate for use in the home. DME does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for DME must be on a NUCC 1500 form. See Section I for billing information.

PROSTHETICS AND ORTHOTICS

Prosthesis is the replacement of a missing body part/organ by an artificial substitute, such as an artificial extremity. Orthosis is any device added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function. P&O does not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement, and are subject to benefit limitations. Claim submission for P&O charges must be on a NUCC 1500 form. See Section I for billing information.

AMBULANCE

Emergency and non-emergency medical transport services are provided for BlueCare insured/member(s) based on benefits and eligibility. Ambulance services do not require pre-admission certification, however, services must be deemed medically necessary to be eligible for reimbursement. Claim submission for ambulance charges must be on a NUCC 1500 form. See Section I for billing information.

INDEPENDENT LAB

A laboratory which is independent both of the attending or consulting physician's office and the hospital. BlueCare products shall provide coverage for services performed at independent laboratories. These services do not require pre-admission certification. Claim submission for independent laboratory charges must be on a NUCC 1500 form. See Section I for billing information.

APPEALS

PROVIDER APPEALS

BlueCare realizes that health care is rapidly changing and often challenging. As your partner in health care, BlueCare offers various internal avenues for providers to render an appeal.

There are (2) two types of appeals that do not involve determination of medical necessity. Claim Administrative Appeals and Terminations.

  1. Administrative Claim Process Appeals – These types of appeals include claim processing including denials for timely filing, questionable level of payment or failure to obtain necessary authorization for non-emergency services. Provider Relations shall provide oversight of all appeals. A record keeping and reporting system shall be in place for all appeals. There will be no further levels of appeals. The provider appeal(s) will be received in Provider Relations and forwarded to the designee. The designee will then gather any and all related information from the provider and any department within BlueCare.

All information shall immediately be presented to the appropriate Regional Manager. Written notification of the final decision shall be sent to the appealing entity within ninety (90) business days from date of the appeal letter

Written Facility Appeals can be sent to:

BlueCare
Provider Relations Department
19 N. Main Street
Wilkes-Barre, PA 18711-0302

Written Professional Appeals can be sent to:

BlueCare
Medical Policy Department
19 N. Main Street
Wilkes-Barre, PA 18711-0302

  1. Administrative -Termination Dispute Process - This is the second type of non –medical determination appeal.
  1. Please refer to Section Q, "Policies", of this manual.
  2. Also refer to your executed FPLIC Agreement,"Termination" section.

If you have any questions, please contact BCNEPA Provider Relations at 570-200-4700 or 1-800-451-4447.

BEHAVIORAL HEALTHCARE PROGRAM

FPLIC contracts directly with behavioral health care providers in order to offer insured/member(s) comprehensive behavioral health care services.

Access to these services is through our agreement with Community Behavioral Healthcare Network of Pennsylvania (CBHNP) who serves as the Regional Referral Center (RRC).

The responsibilities of the Regional Referral Center (RRC) are to:

This centralized system for coordination of services ensures that insured/member(s) will be evaluated and referred to the most appropriate participating facility or professional in a timely manner. Throughout the course of treatment or hospitalization, the RRC will review the insured/member(s) progress within the established plan of treatment, and authorize the use of the insured/member(s) benefits according to established criteria.

Contact the RRC for:

Upon request, criteria for inpatient mental health services can be obtained by contacting the RRC at 1-800-577-3742. For chemical recovery services, BlueCare uses the American Society of Addiction Medicine criteria for any level of care. For information on how to obtain this criteria, also contact the RRC.

BILLING INFORMATION

BILLING POLICIES/PROCEDURES

Electronic claims are to be sent to Blue Cross of NEPA using, either the UB04 or the NUCC1500 billing format and the appropriate revenue, ICD-9 and/or HCPCS/CPT codes. The insured/member(s) is held harmless except for non-covered services, designated copayments, deductibles, co-insurances, etc., or when instructed in writing by FPLIC.

All hard copy claims must be mailed to the following address:

FPLIC/BlueCare
P.O. Box 890179
Camp Hill, PA 17089-0179

Timely Filing

All providers are required to submit claims within the time frames established, per contract.

Pre-admission Testing (PAT) – Payment for pre-admission testing is included in the prospective payment rate for inpatient admissions and for outpatient surgery. Tests performed the day of or the day prior to an inpatient or outpatient admission/surgery are considered part of the inpatient stay/surgery. These services are to be included in the billing.

Coverage for pre-admission testing includes only the usual and specific diagnostic services ordinarily associated with the condition requiring hospitalization, or outpatient surgery.

Detained Baby Claims – Charges incurred for these admissions are to be handled separately from the original mother/baby claims that were submitted for the delivery. The services billed will be for the detained stay only.

Maternity Home Health Visit – When billing the mandated early discharge home health visit, use the remarks section to indicate "Early Discharge Visit". This visit does not require pre-admission certification.

Itemization of Service – When billing for multiple dates of service on one claim (i.e. physical therapy, speech therapy, occupational therapy), please list each date of service in Locator 45 of the UB04 claim form and the charge associated with the date in Locator 47.

Units – The UB04 locator must contain a numerical value of one (1) or higher; zeros will not be accepted.

Outpatient Services – Surgical procedures performed in the following settings are billable as outpatient:

Re-admission

Inpatient and outpatient claims will be examined for re-admissions and clinical correlation.

Claims will be combined based on when a re-admission is expected following an initial discharge, indicating the need for further medical/surgical treatment. Examples include, but are not limited to:

Re-admissions within thirty (30) days of a preceding discharge will be reviewed to determine medical appropriateness of the initial discharge. If the initial discharge is determined to be premature, payment will be adjusted to reflect one episode of care.

Postponement Policy

If the facility must postpone a procedure or test and the insured/member(s) must be re-admitted, one bill should be submitted that encompasses both admissions.

Utilization Review

Inpatient and outpatient claims may be reviewed to substantiate accuracy of billing and payment.

Claims will be reviewed to verify accuracy and completeness of pre-admission certification information. If inaccuracies exist based on actual medical record documentation, payment may be adjusted.

Cases in which an insured/member(s) is admitted and discharged the same day following a procedure will be reviewed for appropriateness of setting and/or accuracy of billing. Payment may be adjusted.

Cases in which an insured/member(s) is transferred to and/or from their acute care or psychiatric areas in the same episode of inpatient care will be combined and reimbursed under one DRG payment.

Delay/Cancellation Policy/Against Medical Advice (AMA)

If a BlueCare insured/member(s) requests a delay or cancellation of an inpatient stay after the insured/member(s) has received some services, and the stay was considered medically necessary, the services which would have been covered on an outpatient basis, should be billed as an outpatient claim. Room and board charges are the insured's/member(s) responsibility.

Insured/Member(s) Liabilities

Any charge rejected due to benefit limitation, lack of covered services or lack of medical necessity becomes the insured's/member(s)' responsibility.

Such charges include, but are not limited to:

Collection of FPLIC insured/member(s) liability & concurrent processing

Your participating office/facility is notified of insured/member(s) liability from your remittance advice/explanation of benefits. All institutional and professional BlueCare Traditional (FPLIC) claims, excluding BlueCare PPO products, undergo concurrent processing. Services are adjudicated under the correct line of business (i.e. medical surgical vs major medical). The provider and insured/member(s) receive only one remittance advice/EOB and the provider receives one payment, if applicable.

Upon notification, the insured/member(s) can be billed for their liability including, deductibles, coinsurance or co-payments. Providers may elect to collect insured/member(s) liability at the time of service. FPLIC would like to caution providers that this avenue may require reimbursements being made back to the insured/member(s).

At no time shall the contracted FPLIC provider collect amounts equating to billed charges at the time of service.

UB04 and NUCC 1500 billing requirements

Please refer to the BCNEPA/FPH/FPLIC Billing Manual available on the BCNEPA Provider Center.

NAVINETsm

Blue Cross of NEPA on behalf of FPLIC, responded to the challenge to simplify and expedite administrative processes by offering providers in our network the web-based system NaviNetsm. This system allows providers to electronically link to Blue Cross of NEPA (FPLIC) for a variety of purposes, including but not limited to:

ELECTRONIC AND PAPER ADJUSTMENTS

FPLIC allows providers who bill in the UB04 format to adjust previously submitted claims either electronically or through the use of the adjustment form. When submitting a BlueCare adjustment form, check the First Priority Life Insurance Company box at the top of the form. The adjustment form can be located on the BCNEPA Provider Center under Forms.

Adjustment, whether electronic or paper, are submitted by participating providers when attempting to:

If you are submitting a late charge bill, please utilize the correct third-digit bill type frequency of "5" (i.e. 135 for outpatient). Late charges should be submitted only when adding a charge on a revenue code that has not previously been billed.

The UB04 Claim Adjustment form should be submitted to:

FPLIC/BlueCare
Claims Department
19 N. Main Street
Wilkes-Barre, PA 18711
Fax # (570) 200-6790

NUCC 1500 adjustments should be submitted via a corrected hardcopy claim and sent to:

FPLIC/Blue Care
P.O. Box 890179
Camp Hill, PA 17089-0179

CLAIM ADJUSTMENT POLICY

Blue Cross of Northeastern Pennsylvania (BCNEPA)/First Priority Health (FPH)/First Priority Life Insurance Company (FPLIC) will not honor any provider (professional/organizational) adjustment requests nor will initiate adjustments if the date of the requested adjustment is:

  1. Greater than four years from claim receive date, or
  2. Ninety days from the last processed date, provided, however, that no less than four years has elapsed from the original claim receive date.
  3. Processing associated with Coordination of Benefits (COB), subrogation, fraud investigations are exempt from this policy.

Effective July 1, 2004, BCNEPA implemented the claim adjustment policy for all product lines. This process will be applicable to provider initiated and BCNEPA/FPH/FPLIC initiated adjustments.

REMITTANCE ADVICE (RA)/EXPLANATION OF BENEFITS (EOB)

All claims payments, denials and adjustments will be documented on a remittance advice (RA)/explanation of benefits (EOB). Retain these forms for your records. If you have any questions, contact the appropriate BlueCare Service Representative. Please refer to the Telephone Directory (Section B, page 1).

OTHER PARTY LIABILITY

Other Party Liability (OPL) provisions were developed primarily to help eliminate duplication of medical payments by First Priority Life Insurance Company (FPLIC). The following information is intended to serve only as general information and to assist you in identifying various situations when you should contact all insurers involved to actually determine the rule in effect.

These OPL provisions:

Primary Payer

The primary plan, or the plan determined to pay first, must provide benefits up to the limits of its contract as if no other insurance coverage existed.

Secondary Payer

If FPLIC is the secondary payer, FPLIC will pay for the insured/member(s)' liability amounts for services rendered up to the limitations of the BlueCare contract.

If our internal files indicate that an insured/member(s) has another insurance carrier that is primary, FPLIC will require an Explanation of Benefits (EOB) from the primary carrier before the claim will be considered for payment. If the EOB from the primary insurance carrier is not submitted with the claim, the claim will be denied as needing an EOB from the primary insurance carrier.

When there is a prior payment from the primary insurance carrier, please report the appropriate value codes as follows:

Submitting balance after Medicare

Utilize the Medicare remittance field which shows the amount paid by Medicare (i.e. "Net Reimbursement" field) and add the deductible or co-insurance amount due.

Medicare payment + Deductible and/or Co-insurance due = Value Code 44 Amount

Use value code A1 or A2 and the amount (Locator 39-41) and indicate the deductible and/or co-insurance due from FPLIC.

Prior payment (Locator 54) is the amount paid by Medicare (i.e. "Net Reimbursement" from the RA)

Estimated amount due (Locator 55) is the amount of the deductible and/or co-insurance due from Blue Care

To verify that your information is correct, do the following calculation

Value Code 44 Amount – (minus) Prior Payment Amount = Deductible or Co-insurance due.

Submitting balance after insurance other than Medicare

Report the following value codes as indicated:

A1 - Deductible Payer A

A2 - Coinsurance Payer A

A3 - Estimated Responsibility Payer A (Prior Payment Amount)

31 - Patient Liability Amount (Non-Covered Services)

Complete Locator 54 on UB04 (prior payment field) reporting the amount paid by the primary insurance.

If you bill hard copy, please attach the other insurance EOB to the applicable billing form, and mail to:

FPLIC/BlueCare
P.O. Box 890179
Camp Hill, PA 17089-0179

If you bill electronically, you may fax the primary carrier's EOB to:

BlueCare (please list specific product name here)
(i.e. BlueCare PPO, BlueCare Traditional, etc.)
Fax Number (570) 200-6790

Determining Primary vs. Secondary Payer

Medicare is primary if the patient is:

Group coverage is primary if the patient is:

Non-Coordination of Benefits Plans

The health insurance plan that has no COB provision pays before a plan that has a COB provision. The non-COB plan shall be considered the primary payer.

Coverage by Two Plans

If the insured/member(s) is covered as an employee on two separate health plans, (i.e. working two jobs), the plan covering the insured longer pays benefits first, including any claims for covered insured's/member(s).

The benefits of the plan that covers the individual as an employee, or insured/member(s) are determined before those of the plan that covers the individual as a dependent.

If an insured/member(s) has coverage under one plan as a laid-off or retired employee, and under another plan as an active employee, the benefits provided by the plan which covers the individual as an active employee are determined before those of the plan which covers the individual as a laid-off or retired employee. The same rule applies to insured/member(s) covered under both policies.

For example:

When determining the benefits for a retiree who is also covered as a dependent of an active employee, the plan that covers the person as a non-dependent (for example, as a retiree) pays before the plan that covers the person as a dependent.

For example:

NOTE: This rule does not apply if the retiree is also a Medicare beneficiary. See the Medicare chart listed on the next page:

Medicare

Status of Covered Insured/Member(s) Employer with less than 20 employees Employer with more than 20 employees but less than 100 Employer with 100 employees or more
Active employee & spouse age 65 or older Disabled employee or dependent under age 65 & eligible for Medicare Retired employee & spouse entitled to Medicare Medicare Primary Medicare Primary Medicare Primary BlueCare Primary Medicare Primary Medicare Primary BlueCare Primary BlueCare Primary Medicare Primary

Dependent Children

BlueCare determines the order of benefit payment for a dependent child by use of the "birthday rule" developed under the guidance of the National Association of Insurance Commissioners (NAIC). The primary coverage for a dependent child is the coverage of the natural parent as an employee whose birthday (month and day, not year) falls earlier in the year. For example, the coverage for a parent born on June 6 would pay benefits for a child before the coverage of a parent born September 2. If both natural parents have the same birthday, the plan that has been covering the parent longer pays first.

Since the birthday rule has not been mandated in all states, there may be some insurance carriers that still follow the male/female (gender) rule. If one coordinating plan uses the birthday rule and the other uses the male/female (gender) rule, both plans will follow the latter.

When parents are separated/divorced, neither the male/female (gender) or birthday rule applies, except in the case of custody.

For children of divorced/separated parents, the order of payers will be as follows:

  1. The health care coverage of the natural parent with custody, as a policy holder, pays first;
  2. The health care coverage of the spouse of the parent with custody, as a policyholder, (step-parent) pays second;
  3. The health care coverage of the natural parent without custody, as a policyholder, pays last.

If there is a court decree that states that one of the natural parents is responsible for the child's health care expenses, that plan pays first. The plan of the other natural parent shall be the secondary plan. FPLIC requires copies of court decrees when applicable.

Newborns

Newborn children of a policyholder or covered dependent (male or female) are covered for the first thirty-one (31) days immediately following birth. Coverage after thirty-one (31) days is contingent upon the policyholder enrolling the newborn child as a dependent within the thirty-one (31) day period.

If both parents have health insurance, the birthday rule is followed to determine the primary and secondary payers.

Medicaid

Medicaid is always the secondary payer, no matter who carries it. It is possible for someone to have Blue Care through an employer and also have Medicaid. Providers can bill Medicaid after payment is received from FPLIC, but Medicaid will only pay up to the amount it normally pays. In most instances, FPLIC will have paid more than Medicaid would pay, therefore, billing Medicaid for any balance will usually not result in any payment. Providers cannot bill an insured/member(s) for any balance after Medicaid pays its usual fee, and are required to accept any payment from Medicaid as payment in full.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

CHAMPUS is health insurance given to active and retired service individuals. Not all service-related individuals have it. However, CHAMPUS is always the last payer (the only exception is that CHAMPUS remains primary payer to Medicaid).

Automobile Insurance

Automobile insurance, as required by the Pennsylvania Motor Vehicle Financial Responsibility Act, is primary over BlueCare coverage. Pennsylvania law does not require coverage for motorcycles, snowmobiles or ATVs. However, if a subscriber chooses to purchase an optional medical coverage policy for their motorcycle, snowmobile or ATV, that coverage will be considered primary over BlueCare coverage.

If a BlueCare insured/member(s) is injured in a motor vehicle accident, or sustains injury due to maintenance or use of a motor vehicle, it is the insured/member(s)/ automobile insurance that is the primary payer.

BlueCare requires the use of value code A3 and a letter of exhaustion from the applicable auto insurance carrier indicating that the subscriber has exhausted the first party benefits along with a copy of the payout sheet indicating the claims that were paid.

If an insured has no auto insurance or does not own a motor vehicle

BlueCare is not automatically primary for claims paid. Under Pennsylvania law, benefits are determined in the following order:

  1. Resident relative: any active automobile insurance of a relative residing within the insured/member(s)' household.
  1. Auto insurance of the vehicle the insured/member(s) was either driving, a passenger in, or hit by at the time of the accident.
  2. Auto insurance from any other motor vehicle involved in the accident.

"Hit and Run" Automobile Accident

If the insured/member(s) was involved in a "Hit and Run" accident and does not possess auto insurance or does not have a resident relative with auto insurance, FPLIC requires the appropriate notarized affidavit of NO AUTOMOBILE INSURANCE and a copy of the police report indicating it was a "Hit and Run" accident.

If no automobile insurance carrier is applicable, BlueCare will coordinate benefits with other applicable health insurance carriers.

NOTE: All notarized affidavits of NO AUTOMOBILE INSURANCE must be forwarded to:

BlueCare/Other Party Liability Department
19 North Main Street
Wilkes-Barre, PA 18711-0302

Worker's Compensation

If a BlueCare insured/member(s) is injured, contracts a disease on the employer's property, or during any company-sponsored sports events or activities, medical claims incurred as a result of that accident are the responsibility of the employer's worker's compensation carrier. Worker's compensation is always considered the primary carrier. FPLIC will review any claim previously denied as work-related upon receipt of a valid worker's compensation denial from the worker's compensation carrier.

Injured on Private Property/Business (other than insured/member(s)' employer)

FPLIC has the right to subrogate claims paid on our insured's behalf if an insured/member(s) is pursuing a possible lawsuit or appealing a denial from another third-party insurance.

School Insurance

When a child attends school, he/she is frequently covered by a small health or accident policy through the school. This policy is for use in case of accidents occurring at school or in school-related activities. Most policies state in the contract that they are "Supplemental Only" or there is a "No Coordination of Benefits" clause, in which case they would be in the last payer position.